Norovirus genotypes causing gastroenteritis outbreaks in Finland 1998–2002

Norovirus outbreaks due to contaminated drinking water and probable person-to-person transmission, Kerala, India, 2021

BACKGROUND

In July 2021, the Alappuzha district in Kerala, India, reported an unexpected number of acute gastroenteritis (772) cases (Outbreak A). On October 10, 2021, a university in Wayanad, Kerala, reported 25 acute gastroenteritis cases (Outbreak B). We described both the outbreaks and determined the agent, source and risk factors.

METHODS

We defined a suspected case as the occurrence of vomiting or at least three episodes of loose stools within 24 h and a confirmed case as those with stool samples/rectal swabs positive for norovirus. We did a matched case-control study in Outbreak A and a retrospective cohort study in Outbreak B. We calculated the adjusted odds ratio (aOR) in outbreak A, relative risk (aRR) in outbreak B and population attributable fraction (PAF). We tested stool and water samples for bacteria and viruses.

RESULTS

We identified Group II norovirus in stool samples in both outbreaks and 4/5 water samples in Outbreak A. Suspected norovirus infection was associated with drinking inadequately boiled water from the municipal water supply in outbreak A [aOR: 4.5; 95 % C.I: 1.2-15.8; PAF: 0.23] and well water in hostels in outbreak B [aRR: 2.2; 95 % C.I: 1.2-3.9; PAF: 0.15]. In Outbreak A, groundwater from tube wells was mixed in the municipal water supply overhead tanks without chlorination.

CONCLUSION

The gastroenteritis outbreaks were caused by Group II norovirus due to the consumption of inadequately boiled contaminated groundwater (outbreak A) and well water (outbreak B). We recommended superchlorination of overhead tanks and wells and boiled water for drinking.

Acute gastroenteritis outbreak associated with multiple and rare norovirus genotypes after storm events in Santa Catarina, Brazil

Norovirus is a major cause of acute diarrheal disease (ADD) outbreaks worldwide. In the present study, we investigated an ADD outbreak caused by norovirus in several municipalities of Santa Catarina state during the summer season, southern Brazil in 2023. As of the 10th epidemiological week of 2023, approximately 87 000 ADD cases were reported, with the capital, Florianópolis, recording the highest number of cases throughout the weeks. By using RT-qPCR and sequencing, we detected 10 different genotypes, from both genogroups (G) I and II. Some rare genotypes were also identified. Additionally, rotavirus and human adenovirus were sporadically detected among the ADD cases. Several features of the outbreak suggest that sewage-contaminated water could played a role in the surge of ADD cases. Storm events in Santa Catarina state that preceded the outbreak likely increased the discharge of contaminated wastewater and stormwater into water bodies, such as rivers and beaches during a high touristic season in the state. Climate change-induced extreme weather events, including intensified rainfall and frequent floods, can disturb healthcare and sanitation systems. Implementing public policies for effective sanitation, particularly during peak times, is crucial to maintain environmental equilibrium and counter marine pollution.

Norovirus GII.3[P12] Outbreak Associated with the Drinking Water Supply in a Rural Area in Galicia, Spain, 2021

Noroviruses are likely to be underrecognized in most suspected waterborne outbreaks. Therefore, effective norovirus detection and the early recognition of water as a possible source of infection are important to reduce morbidity as appropriate steps are taken to control the source.

High Prevalence and Diversity of Caliciviruses in a Community Setting Determined by a Metagenomic Approach

We recently carried out a metagenomic study to determine the fecal virome of infants during their first year of life in a semirural community in Mexico. A total of 97 stool samples from nine children were collected starting 2 weeks after birth and monthly thereafter until 12 months of age. In this work, we describe the prevalence and incidence of caliciviruses in this birth cohort. We found that 54 (56%) and 24 (25%) of the samples were positive for norovirus and sapovirus sequence reads detected by next-generation sequencing, respectively. Potential infections were arbitrarily considered when at least 20% of the complete virus genome was determined. Considering only these samples, there were 3 cases per child/year for norovirus and 0.33 cases per child/year for sapovirus. All nine children had sequence reads related to norovirus in at least 2 and up to 10 samples, and 8 children excreted sapovirus sequence reads in 1 and up to 5 samples during the study. The virus in 35 samples could be genotyped. The results showed a high diversity of both norovirus (GI.3[P13], GI.5, GII.4, GII.4[P16], GII.7[P7], and GII.17[P17]) and sapovirus (GI.1, GI.7, and GII.4) in the community. Of interest, despite the frequent detection of caliciviruses in the stools, all children remained asymptomatic during the study. Our results clearly show that metagenomic studies in stools may reveal a detailed picture of the prevalence and diversity of gastrointestinal viruses in the human gut during the first year of life.

IMPORTANCE Human caliciviruses are important etiological agents of acute gastroenteritis in children under 5 years of age. Several studies have characterized their association with childhood diarrhea and their presence in nondiarrheal stool samples. In this work, we used a next-generation sequencing approach to determine, in a longitudinal study, the fecal virome of infants during their first year of life. Using this method, we found that caliciviruses can be detected significantly more frequently than previously reported, providing a more detailed picture of the prevalence and genetic diversity of these viruses in the human gut during early life.

An Outbreak of Norovirus Infections Among Lunch Customers at a Restaurant, Tampere, Finland, 2015

On January 29, 2015, the city of Tampere environmental health officers were informed of a possible foodborne outbreak among customers who had eaten lunch in restaurant X. Employees of electric companies A and B had a sudden onset of gastrointestinal symptoms. We conducted a retrospective cohort study to identify the vehicle, source, and causative agent of the outbreak. A case was defined as an employee of companies A or B with diarrhea and/or vomiting who ate lunch at Restaurant X on January 26, 2015. All employees of the companies attending the implicated lunch were invited to participate in the cohort study. Environmental investigation was conducted. Twenty-one responders were included in statistical analysis, of which 11 met with the case definition. Of the 15 food items consumed by participants, four food items were associated with gastroenteritis. Of four kitchen staff, three tested positive for norovirus GIP7, the strain was found earlier in the community. No patient samples were obtained. Level of hygiene in the kitchen was inadequate. Infected kitchen staff probably transmitted norovirus by inadequate hygiene practices. No new cases associated with Restaurant X were reported after the hygiene practices were improved.

Noroviruses: epidemiology, immunity and prospects for prevention

In recent years, noroviruses have become recognized as an important cause of both sporadic and epidemic acute gastroenteritis (AGE), largely due to the improved availability of broadly reactive real-time RT-PCR (TaqMan-based RT-PCR) assays. While there is substantial diversity among noroviruses, one specific genotype, GII.4, is the most common etiology in sporadic and epidemic AGE. Outbreaks of norovirus AGE most commonly occur in healthcare facilities and restaurants and result in significant morbidity and mortality and substantial healthcare costs. Norovirus vaccine development is progressing, and Phase I and II human trials have shown proof-of-principle that norovirus vaccines can reduce illness and infection.

Application of salivary antibody immunoassays for the detection of incident infections with Norwalk virus in a group of volunteers

Norovirus infection is the most common cause of acute gastroenteritis in developed countries. Developing an assay based on a non-invasive biomarker for detecting incident norovirus infections could improve disease surveillance and epidemiological investigations. This project involved analysis of IgA and IgG norovirus-specific antibody responses in saliva samples from a Norwalk virus (Genogroup I, genotype 1 norovirus) challenge study involving infected and symptomatic, and non-infected asymptomatic individuals. Saliva was collected at the challenge, and two weeks and 40 days post-challenge. Samples were analyzed using the Luminex fluorometric and Meso Scale Discovery (MSD) electrochemiluminescence immunoassays. Recombinant P domains of Norwalk virus capsid protein, as well as similar recombinant proteins of two genogroup II noroviruses (VA387 and VA207) were used as antigens. Immunoconversions were defined as >4-fold increase in antibody responses to the norovirus antigens. Various sample pre-treatment options, buffers, saliva dilution ratios, and data adjustment approaches to control for sample-to-sample variability in saliva composition were compared using the Luminex assay. The results suggest that adjusting responses to the norovirus antigens for responses to the protein purification tag, glutathione-S-transferase (GST), significantly improved the odds of producing a correct immunoconversion test result. IgG-based tests were more accurate compared to IgA-based tests. At optimal conditions, both Luminex and MSD assays for Norwalk-specific IgG antibodies correctly identified all infected and non-infected individuals. There was no evidence of cross-reactivity of anti-Norwalk virus antibodies with genogroup II noroviruses. These results suggest that salivary antibody responses can be used for the detection of incident infections with Norwalk virus in prospective surveys.

Emerging and re-emerging enteric viruses causing multinational foodborne disease outbreaks

ABSTRACT: 

The development of molecular detection methods has led to recognition of viruses as important foodborne pathogens. The most common foodborne virus is norovirus, which together with HAV are transmitted via food consumed raw, such as shellfish, fresh produce and soft fruit. HEV is increasingly being recognized as an emerging foodborne virus in developed countries. The transmission route of HEV includes zoonotic transmission in association with pork products. Ongoing changes in food commerce and production from national to internationally-distributed foodstuffs are leading to widespread infections and multinational outbreaks. Recent large viral outbreaks have been linked to oysters, frozen berries and semidried tomatoes.

Outbreak of gastroenteritis caused by norovirus GII.4 Sydney variant after a wedding reception at a resort/activity centre, Finland, August 2012

In August 2012, an outbreak of gastroenteritis occurred among 88 persons attending a wedding reception at a resort/activity centre in Ylöjärvi, Finland. Of 39 interviewed guests, 23 met the case definition. Two persons were hospitalized. Epidemiological, laboratory and environmental investigations were conducted to characterize the outbreak and to recommend control measures. Investigation confirmed the presence of a new strain of norovirus GII.4 Sydney variant in stool specimens obtained from two wedding guests and on several environmental surfaces in the centre. In the questionnaire study, none of the foods or beverages served during the reception were significantly associated with the illness. Additional cases of gastroenteritis that occurred at the centre before and after the wedding reception supported the hypothesis of environmental transmission of norovirus. After thorough cleansing and disinfection and 1 week's quarantine, no new cases with symptoms typical for norovirus infection were identified at the centre.

Epidemiological and molecular analysis of a waterborne outbreak of norovirus GII.4

Contaminated water is one of the main sources of norovirus (NoV) gastroenteritis outbreaks globally. Waterborne NoV outbreaks are infrequently attributed to GII.4 NoV. In September 2009, a NoV outbreak affected a small school in Guangdong Province, China. Epidemiological investigations indicated that household use water, supplied by a well, was the probable source (relative risk 1·9). NoV nucleic acid material in concentrated well-water samples was detected using real-time RT-PCR. Nucleotide sequences of NoV extracted from diarrhoea and well-water specimens were identical and had the greatest sequence identity to corresponding sequences from the epidemic strain GII.4-2006b. Our report documents the first laboratory-confirmed waterborne outbreak caused by GII.4 NoV genotype in China. Our investigations indicate that well water, intended exclusively for household use but not for consumption, caused this outbreak. The results of this report serve as a reminder that private well water intended for household use should be tested for NoV.

Molecular and epidemiological features of gastroenteritis outbreaks involving genogroup I norovirus in Victoria, Australia, 2002-2010

GI noroviruses are relatively rare and systematic studies of the molecular epidemiology of GI norovirus outbreaks are lacking. The current study examined the molecular virology of GI norovirus outbreaks in Victoria, Australia (2002-2010). Of 1,617 norovirus outbreaks identified, 69 (4.3%) were associated with GI norovirus alone, 1,540 (95.2%) with GII norovirus alone and 8 (0.5%) with GI + GII. Some differences between GI and GII outbreak epidemiology were found. GI outbreaks peaked in the 2-month period November/December whereas GII outbreaks peaked in the 2-month period September/October and GI norovirus outbreaks were significantly more common in non-healthcare settings (37.7%) than GII outbreaks (9.5%). ORF 1/ORF 2 genotypes found in the 69 outbreaks involving GI norovirus alone were: GI.2/GI.2, 7 outbreaks; GI.2/GI.6, 18 outbreaks; GI.3b/GI.3, 14 outbreaks; GI.4/GI.4, 21 outbreaks; GI.8/GI.8, one outbreak; GI.d/GI.3, four outbreaks; and GI.e/GI.13, one outbreak. The current study appears to be the first to have identified the recombinant form, GI.2/GI.6. Whereas GI.2/GI.6 and GI.3b/GI.3 outbreaks occurred with equal frequency in both healthcare and non-healthcare settings, GI.4/GI.4 occurred predominantly in healthcare settings. GI ORF 1/ORF 2 genotypes found in the eight outbreaks involving GI + GII norovirus were GI.2/GI.6, GI.3b/GI.3, and GI.4/GI.4, indicating GI genotypes in GI + GII outbreaks were similar to those found in outbreaks involving GI alone. Apparent differences in the evolution of different GI genotypes were noted. GI.2/GI.2, GI.2/GI.6, and GI.4/GI.4 strains tended to undergo periodic shifts in nucleotide sequence whereas various GI.3b/GI.3 strains tended to circulate simultaneously.

Marked genomic diversity of norovirus genogroup I strains in a waterborne outbreak

Marked norovirus (NoV) diversity was detected in patient samples from a large community outbreak of gastroenteritis with waterborne epidemiology affecting approximately 2,400 people. NoV was detected in 33 of 50 patient samples examined by group-specific real-time reverse transcription-PCR. NoV genotype I (GI) strains predominated in 31 patients, with mixed GI infections occurring in 5 of these patients. Sequence analysis of RNA-dependent polymerase-N/S capsid-coding regions (∼900 nucleotides in length) confirmed the dominance of the GI strains (n = 36). Strains of NoV GI.4 (n = 21) and GI.7 (n = 9) were identified, but six strains required full capsid amino acid analyses (530 to 550 amino acids) based on control sequencing of cloned amplicons before the virus genotype could be determined. Three strains were assigned to a new NoV GI genotype, proposed as GI.9, based on capsid amino acid analyses showing 26% dissimilarity from the established genotypes GI.1 to GI.8. Three other strains grouped in a sub-branch of GI.3 with 13 to 15% amino acid dissimilarity to GI.3 GenBank reference strains. Phylogenetic analysis (2.1 kb) of 10 representative strains confirmed these genotype clusters. Strains of NoV GII.4 (n = 1), NoV GII.6 (n = 2), sapovirus GII.2 (n = 1), rotavirus (n = 3), adenovirus (n = 1), and Campylobacter spp. (n = 2) were detected as single infections or as mixtures with NoV GI. Marked NoV GI diversity detected in patients was consistent with epidemiologic evidence of waterborne NoV infections, suggesting human fecal contamination of the water supply. Recognition of NoV diversity in a cluster of patients provided a useful warning marker of waterborne contamination in the Lilla Edet outbreak.

Prevalence of norovirus GII-4 antibodies in Finnish children

Noroviruses (NoVs) are the second most common cause of viral gastroenteritis after rotavirus in children. NoV genotype GII-4 has emerged as the major type not only in outbreaks of NoV gastroenteritis but also endemic gastroenteritis among infants and young children worldwide. Using baculovirus-insect cell system virus-like particles (VLPs) of NoV genotype GII-4 and an uncommon genotype GII-12 were produced. These VLPs were used in enzyme-linked immunosorbent assays (ELISA) for detection of NoV-specific immunoglobulin G (IgG) and IgA antibodies in 492 serum specimens from Finnish children 0-14 years of age collected between 2006 and 2008. NoV IgG antibody prevalence was 47.3% in the age group 7-23 months and increased up to 91.2% after the age of 5 years. Avidity of NoV IgG antibodies was low in the primary infections while high avidity antibodies were detected in the recurrent infections of the older children. In GII-4 infections, the homologous antibody response to GII-4 VLPs was stronger than to GII-12 VLPs but cross-reactivity between GII-4 and GII-12 was observed. Binding of GII-4 VLPs to a putative carbohydrate antigen receptor H-type 3 could be blocked by sera from children not infected with NoV during a waterborne outbreak of acute gastroenteritis. Therefore, protection against NoV infection correlated with strong blocking activity.

Norovirus genotypes in endemic acute gastroenteritis of infants and children in Finland between 1994 and 2007

Noroviruses are, after rotaviruses, the second most common causative agents of acute gastroenteritis in young children. We studied norovirus genotypes in faecal specimens collected from Finnish children followed-up prospectively in rotavirus vaccine trials. Almost 5000 faecal specimens collected from cases of acute gastroenteritis were examined using reverse transcriptase-PCR. A total of 1172 cases (25% of all acute gastroenteritis) were associated with noroviruses. Of these, 96% were genogroup GII. GII.4 was the most common genotype (46%) throughout the study period but the proportion of this genotype varied in different norovirus epidemic seasons. Additional norovirus genotypes detected were: GII.7 (15%), GII.3 (14%), GII.1 (9%), GII.b (7%), GII.2 (3%), and GI.3 (2%). GII.4 dominated during the following years: 1998-1999 (75%), 2002-2003 (88%) and 2006-2007 (98%) while recombinant genotype GII.b was dominant between 2003 and 2004 (83%). In conclusion, genotypes GII.4 and GIIb have emerged as predominant norovirus genotypes in endemic gastroenteritis affecting young infants and children in Finland.

Human norovirus infection: surveillance and source tracking

The clinical importance of noroviruses has increased in recent years. It is challenging to control the annual gastroenteritis and vomiting outbreaks caused by noroviruses in hospital wards and also long-term care facilities. This problem is partly due to the repeated emergence of highly penetrant genotype GII.4 variants that cause global epidemics. Consequently, this has led to an increased awareness of norovirus receptor selection and the population immunity characteristics that drive the evolution of the virus. Noroviruses mainly transmit from person to person by the feco–oral route and also via food, water and environmental fomites. International norovirus surveillance helps in source-tracking and in being able to follow the dissemination of viruses with food products in addition to the early detection of emerging variants.

Norovirus GII-4 causes a more severe gastroenteritis than other noroviruses in young children

Norovirus (NoV) GII-4 has emerged as the predominant NoV genotype in outbreaks of gastroenteritis worldwide. We determined clinical features of NoV GII-4 associated acute gastroenteritis (AGE) in comparison with AGE associated with other NoV types in infants during seasons 2001 and 2002. During the prospective follow-up period, 128 primary infections of AGE due to NoV were identified in 405 infants; of these, GII-4 was found in 40 cases (31%). NoV GII-4 was associated with longer duration of diarrhea and vomiting than other NoV genotypes, suggesting greater virulence of NoV GII-4.

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.

SYBR Green based real-time RT-PCR assay for detection and genotype prediction of bovine noroviruses and assessment of clinical significance in Norway

A novel SYBR Green based real-time RT-PCR assay for detection of genogroup III bovine noroviruses (BoNoV) was developed and the assay applied to 419 faecal samples from calves with and without diarrhoea. The samples were obtained from 190 Norwegian dairy and beef herds. BoNoV was detected in 49.6% of the samples from 61.1% of the herds indicating that BoNoV is ubiquitous in Norway. The overall prevalence was not significantly different in diarrhoea and non-diarrhoea samples. Analyses of polymerase gene sequences revealed both genotype III/1 and III/2 with genotype III/2 (Newbury2-like) being the most prevalent. Detected capsid sequences were restricted to Newbury2-like and the chimeric Bo/Thirsk10/00/UK strain. The RNA polymerase genotypes of the circulating BoNoVs in Norway were predicted by melting temperature analysis. Additional data from a challenge experiment suggest that a high proportion of young calves are shedding low levels of BoNoV for a prolonged time after recovering from the associated diarrhoea. The findings may explain some of the discrepancies in detection rates from previous studies and explain why some studies have failed to detect significant prevalence differences between calves with and without diarrhoea. It may also shed new light on some epidemiological aspects of norovirus infections.

Multiple norovirus outbreaks among workplace canteen users in Finland, July 2006

Multiple gastroenteritis outbreaks occurred between 25 and 31 July 2006 in 10 workplace canteens in south-western Finland. One vegetable processing plant provided raw vegetables to all the canteens. We conducted cohort studies in the three most visited canteens and environmental investigations in the kitchens and the plant. Patients' stools, food, water and environmental samples were tested for enteric bacteria and viruses. Of the three canteens, 150/273 respondents (response rate 82%) had gastroenteritis. Consumption of mixed raw vegetables was significantly associated with the illness but no single vegetable explains the outbreak. An identical norovirus GII.1 genotype was detected from all genotyped patient samples. Water, food, and environmental samples were negative for norovirus. The facilities had appropriate hygienic conditions and no staff member had gastroenteritis prior to the outbreak. Tracing back the vegetables to the farm level proved unsuccessful. This was the largest foodborne norovirus outbreak in Finland.

Genetic analysis of norovirus in children affected with acute gastroenteritis in Beijing, 2004-2007

BACKGROUND

Noroviruses (NoVs) are a major cause of acute gastroenteritis in children, but prevalence and circulation of NoVs in China have not been well characterized.

OBJECTIVES

To determine the dominant circulating NoV genotypes and strains associated with pediatric cases of acute gastroenteritis in Beijing, China.

STUDY DESIGN

Fecal samples were obtained from 1126 children affected with acute gastroenteritis in Beijing from March 2004 to November 2007. NoV RNA was amplified, sequenced, and phylogenetically analyzed to determine the dominant circulating genotypes and strains.

RESULTS

NoVs were detected in 8.88% of patients, GII.4 being the dominant genotype. Ehime/05-30 was the dominant strain during 2004-2005, whereas 2006b dominated during 2006-2007. The homology of nucleotide and amino acid sequences among full-length VP1 of 15 randomly selected NoV strains was 91.6-99.6% and 94.5-99.6%, respectively. Recombination between NoV genotypes was frequent among the isolates.

CONCLUSIONS

The predominant circulating genotype of NoV infections in Beijing is GII.4, but the dominant strains of this virus responsible for gastroenteritis epidemics are evolving rapidly. A global surveillance network may be needed to identify trends in molecular evolution of NoVs for prevention of future epidemics.

Aetiology and epidemiology of viral gastroenteritis outbreaks in Catalonia (Spain) in 2004-2005

BACKGROUND

Acute infectious gastroenteritis causes substantial morbidity and economic loss.

OBJECTIVE

The aetiology, epidemiology, and clinical features of acute viral gastroenteritis outbreaks reported during 1 year in Catalonia were investigated.

STUDY DESIGN

This was a population-based study in which enzyme immunoassay and reverse transcriptase-polymerase chain reaction (RT-PCR) techniques were used to determine the presence of virus in stool specimens from outbreaks clinically and epidemiologically compatible with a viral aetiology and negative for bacteria, parasites and toxins.

RESULTS

Sixty outbreaks affecting 1791 people were evaluated. Fifty-five outbreaks were positive for norovirus, four were positive for norovirus and other microorganisms (adenovirus, astrovirus, S. Typhimurium and V. parahaemolyticus in one each). Thirty-seven percentage of the outbreaks occurred in collective catering; 18.3% in nursing homes; 10% in hospitals and long-term-care facilities. Foodborne transmission accounted for 50% of outbreaks. Norovirus genotype GGII.4 accounted for 42% of all the outbreaks, being more prevalent in nursing homes, hospital and long-term-care facilities.

CONCLUSIONS

The large number of norovirus outbreaks and resulting health service demand and absenteeism indicate that acute gastroenteritis caused by norovirus is an important health problem in Catalonia. Preventive measures should target education and control of food handlers, and immediate specific control measures should be adopted in institutions.

Epidemiology of foodborne norovirus outbreaks in Catalonia, Spain

Background

Noroviruses are one of the principal biological agents associated with the consumption of contaminated food. The objective of this study was to analyse the size and epidemiological characteristics of foodborne outbreaks of gastroenteritis in Catalonia, a region in the northeast of Spain.

Methods

In all reported outbreaks of gastroenteritis associated with food consumption, faecal samples of persons affected were analysed for bacteria and viruses and selectively for parasites. Study variables included the setting, the number of people exposed, age, sex, clinical signs and hospital admissions. The study was carried out from October 2004 to October 2005.

Results

Of the 181 outbreaks reported during the study period, 72 were caused by Salmonella and 30 by norovirus (NoV); the incidence rates were 14.5 and 9.9 per 100,000 person-years, respectively. In 50% of the NoV outbreaks and 27% of the bacterial outbreaks (p = 0.03) the number of persons affected was ≥10; 66.7% of NoV outbreaks occurred in restaurants; no differences in the attack rates were observed according to the etiology. Hospitalizations were more common (p = 0.03) in bacterial outbreaks (8.6%) than in NoV outbreaks (0.15%). Secondary cases accounted for 4% of cases in NoV outbreaks compared with 0.3% of cases in bacterial outbreaks (p < 0.001)

Conclusion

Norovirus outbreaks were larger but less frequent than bacterial outbreaks, suggesting that underreporting is greater for NoV outbreaks. Food handlers should receive training on the transmission of infections in diverse situations. Very strict control measures on handwashing and environmental disinfection should be adopted in closed or partially-closed institutions.

Norovirus recombination

RNA recombination is a significant driving force in viral evolution. Increased awareness of recombination within the genus Norovirus of the family Calicivirus has led to a rise in the identification of norovirus (NoV) recombinants and they are now reported at high frequency. Currently, there is no classification system for recombinant NoVs and a widely accepted recombinant genotyping system is still needed. Consequently, there is duplication in reporting of novel recombinants. This has led to difficulties in defining the number and types of recombinants in circulation. In this study, 120 NoV nucleotide sequences were compiled from the current GenBank database and published literature. NoV recombinants and their recombination breakpoints were identified using three methods: phylogenetic analysis, SimPlot analysis and the maximum chi2 method. A total of 20 NoV recombinant types were identified in circulation worldwide. The recombination point is the ORF1/2 overlap in all isolates except one, which demonstrated a double recombination event within the polymerase region.

Waterborne norovirus outbreaks

Noroviruses (NoVs) are the most common nonbacterial causative agents of waterborne outbreaks. Due to the mild and short-lived disease of gastroenteritis, even large epidemics may go unnoticed, since patients do not necessarily visit a doctor. NoVs have several means by which to survive both in the environment and in a population. The nonenveloped small virus retains its infectivity in the environment, and particularly in cold water, for a long time. Unlike most enteric viruses, it causes disease both in children and adults. A large number of genotypes combined with a small infective dose and short-term immunity guarantee efficient circulation of these viruses. The world of NoVs has been revealed to us predominantly by molecular methods. Having learned to detect these viruses first in patients, the emphasis is now in searching for methods sensitive enough to find them in environmental samples. In this review, the latest methods and their use in monitoring of these viruses are discussed.

Genetic heterogeneity, evolution, and recombination in noroviruses

Norovirus is one of the most common causes of nonbacterial gastroenteritis in humans. A total of 603 fecal specimens collected from sporadic pediatric cases of acute gastroenteritis in Japan from 2004 to 2005 were tested for the presence of norovirus by RT-PCR. It was found that 51 (8.5%) specimens were positive for norovirus. The norovirus genotypes detected in this study were GII/1, GII/2, GII/3, GII/4, GII/6, and GII/7. Of these, GII/3 was the most predominant (52.9%), followed by GII/4 (37.2%) and others. It was noticed that four distinct types of recombinant noroviruses were co-circulating and the variant norovirus GIIb suddenly emerged to be the leading strain in Japan for the first time. A novel norovirus nomenclature was proposed, in which worldwide noroviruses were classified into seven distinct genogroups (I-VII). Norovirus GI and GII consisted of 16 genotypes with 32 subgenotypes and 23 genotypes with 34 subgenotypes, respectively. Of note, human and porcine noroviruses had a close genetic relationship within GII. Interestingly, multiple short amino acid motifs located at N terminus, S domain, P1 domain, P2 domain, and C terminus of capsid gene correctly defined the phylogenetic norovirus genogroups, genotypes, and subgenotypes. Another interesting feature of the study was the identification of eight hitherto unreported recombinant noroviruses. It was noteworthy that three different types (intergenogroup, intergenotype, and intersubgenotype) of recombination in noroviruses were also found. This is the first report to demonstrate the existence of intergenogroup and intersubgenotype recombinations in noroviruses and highlights a possible route of zoonoses in humans because porcine, bovine and murine noroviruses belong to genogroups II, III, and V, respectively.

Molecular epidemiology of norovirus outbreaks in Norway during 2000 to 2005 and comparison of four norovirus real-time reverse transcriptase PCR assays

During the period from January 2000 to August 2005 a total of 204 outbreaks of norovirus gastroenteritis were diagnosed at the Norwegian Institute of Public Health. A clear increase in the norovirus activity was seen in healthcare institutions during the winter seasons. Polymerase sequence analysis of norovirus strains from 122 outbreaks showed that 112 were caused by GII strains (91.8%). Two norovirus variants seen during the study period-GIIb and GII.4-were predominant between January 2000 and September 2002, whereas GII.4 was predominant from September 2002 onward. The highest norovirus activity was seen during the 2002-2003 and 2004-2005 seasons with the emergence of new GII.4 variants. This study describes the molecular epidemiology of norovirus strains circulating in Norway during the five previous seasons and compares four norovirus real-time reverse transcriptase PCR assays. A suitable assay for routine diagnostics is suggested.

Real-time detection of noroviruses in surface water by use of a broadly reactive nucleic acid sequence-based amplification assay

Noroviruses are the most common agents causing outbreaks of viral gastroenteritis. Outbreaks originating from contaminated drinking water and from recreational waters have been described. Due to a lack of cell culture systems, noroviruses are detected mostly by molecular methods. Molecular detection assays for viruses in water are often repressed by inhibitory factors present in the environment, like humic acids and heavy metals. To study the effect of environmental inhibitors on the performance of nucleic acid sequence-based amplification (NASBA), we developed a real-time norovirus NASBA targeting part of the RNA-dependent RNA polymerase (RdRp) gene. Specificity of the assay was studied with 33 divergent clones that contained part of the targeted RdRp gene of noroviruses from 15 different genogroups. Viral RNA originated from commercial oysters, surface waters, and sewage treatment plants in The Netherlands. Ninety-seven percent of the clones derived from human noroviruses were detected by real-time NASBA. Two clones containing animal noroviruses were not detected by NASBA. We compared the norovirus detection by real-time NASBA with that by conventional reverse transcriptase PCR (RT-PCR) with large-volume river water samples and found that inhibitory factors of RT-PCR had little or no effect on the performance of the norovirus NASBA. This consequently resulted in a higher sensitivity of the NASBA assay than of the RT-PCR. We show that by combining an efficient RNA extraction method with real-time NASBA the sensitivity of norovirus detection in water samples increased at least 100 times, which consequently has implications for the outcome of the infectious risk assessment.

Detection of norovirus antigens from recombinant virus-like particles and stool samples by a commercial norovirus enzyme-linked immunosorbent assay kit

The commercial norovirus enzyme-linked immunosorbent assay kit was evaluated for its reactivity to recombinant virus-like particles and the detection of natural viruses from stool samples of Japanese infants and children with sporadic acute gastroenteritis compared to reverse transcription-PCR. The kit had a sensitivity of 76.3% and a specificity of 94.9%. Our results clearly indicated that the kit allows the detection of the most prevalent genotype, GII/4. In order to increase the sensitivity of the kit, the reactivity with norovirus of GII/3 and GII/6 genotypes needs to be improved.

Applicability of microarray technique for the detection of noro- and astroviruses

Noroviruses and astroviruses are widespread viral agents causing gastroenteritis. Noroviruses are actually a diverse group of viruses. A new microarray-based detection method is presented for both noro- and astroviruses. This method enables simultaneous identification of genogroups and types of noro- and astroviruses. For pre-amplification, the monoplex- and multiplex-RT-PCR assays were applied to test sensitivity. The 202 specimens were used to determine the specificity, precision, and accuracy of the microarray. Stool samples representing 13 of norovirus GI and GII genotypes were assayed. The microarray detected all but one genotype. In a panel of 74 stool samples, 45 tested positive for norovirus by microarray, against 35 by a conventional PCR-method. In addition, microarray detected some double infections. In a panel of archival samples, astroviruses of genotype 4 frequently emerged in Finland from 1977 to 1997. This study demonstrates that microarray is useful for simultaneous monitoring of several viruses and their subtypes. Microarray provides a convenient tool for the detection of RNA viruses for which frequent changes in the panel of detection primers may be required.

The epidemiologic and clinical importance of norovirus infection

Noroviruses are a major cause of sporadic cases and epidemic outbreaks of gastroenteritis. The development of molecular diagnostic assays has led to an increased recognition of the significance of these viruses as causes of gastroenteritis in all age groups. This article reviews the epidemiology, clinical manifestations and pathogenesis of norovirus infection, and it describes the diagnostic and therapeutic approaches to this disease.

Norovirus outbreaks from drinking water

As part of an intensified monitoring program for foodborne disease outbreaks in Finland, waterborne outbreaks were investigated for viruses. The diagnostic procedure included analysis of patients' stool samples by electron microscopy and reverse transcription-polymerase chain reaction (RT-PCR) for noroviruses and astroviruses. When these test results were positive for a virus, the water sample was analyzed. Virus concentration was based on positively charged filters from 1-L samples. Of the total 41 waterborne outbreaks reported during the observation period (1998-2003), samples from 28 outbreaks were available for analysis. As judged by RT-PCR results from patient samples, noroviruses caused 18 outbreaks. In 10 outbreaks, the water sample also yielded a norovirus. In all but 1 instance, the amplicon sequence was identical to that recovered from the patients. The ubiquity of waterborne norovirus outbreaks calls for measures to monitor water for viruses.