Molecular and clinical epidemiology of norovirus outbreaks in Spain during the emergence of GII.4 2012 variant

Epidemiology of GII.4 and GII.2 norovirus outbreaks in closed and semi-closed institutions in 2017 and 2018

Norovirus infections are a leading cause of acute gastroenteritis outbreaks worldwide, with genotypes GII.2 and GII.4 being the most prevalent. The aim of this study was to compare the characteristics of GII.2 and GII.4 norovirus outbreaks reported in Catalonia in closed or semi-closed institutions in 2017 and 2018. The epidemiological and clinical characteristics of GII.2 and GII.4 outbreaks were compared using the chi-square test or Fisher's exact test for categorical variables and the Mann-Whitney U test for continuous variables. Odds ratios and their 95% confidence intervals were estimated. 61 outbreaks were reported: GII.4 was the causative agent in 12 outbreaks (30%) and GII.2 in 9 outbreaks (22.5%). GII.2 outbreaks were detected more frequently in schools or summer camps (66.7%) and GII.4 outbreaks in nursing homes (91.7%) (p = 0.01). Ninety-three people were affected in GII.2 outbreaks and 94 in GII.4 outbreaks. The median age was 15 years (range: 1-95 years) in GII.2 outbreaks and 86 years (range: 0-100 years) in GII.4 outbreaks (p < 0.001). Nausea, abdominal pain, and headache were observed more frequently in persons affected by GII.2 outbreaks (p < 0.05). Symptomatic cases presented a higher viral load suggestive of greater transmission capacity, although asymptomatic patients presented relevant loads indicative of transmission capacity.

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.

Epidemiological and Genetic Characterization of Norovirus Outbreaks That Occurred in Catalonia, Spain, 2017–2019

Molecular characterization of human norovirus (HuNoV) genotypes enhances the understanding of viral features and illustrates distinctive evolutionary patterns. The aim of our study was to describe the prevalence of the genetic diversity and the epidemiology of the genotypes involved in HuNoV outbreaks in Catalonia (Spain) between 2017 and 2019. A total of 100 HuNoV outbreaks were notified with the predominance of GII (70%), followed by GI (27%) and mixed GI/GII (3%). Seasonality was observed for GII outbreaks only. The most prevalent genotypes identified were GII.4[P31] Sydney 2012, GII.4[P16] Sydney 2012 and GII.2[P16]. As compared to person-to-person (P/P) transmitted outbreaks, foodborne outbreaks showed significantly higher attack rates and lower duration. The average attack rate was higher in youth hostel/campgrounds compared to nursing homes. Only genotypes GI.4[P4], GII.2[P16], GII.4[P16], GII.4[P31] and GII.17[P17] were consistently detected every year, and only abundance of GII.2[P16] showed a negative trend over time. GII.4 Sydney 2012 outbreaks were significantly associated to nursing homes, while GII.2[P16] and GI.3[P3] were most frequently identified in youth hostel/campgrounds. The average attack rate was significantly higher when comparing GII.2[P16] vs. GI.4[P4], GII.2[P16] vs. GII.4[P31] Sydney 2012, and GII.6[P7] vs. GII.4[P31] Sydney 2012. No correlations were found between genotype and outbreak duration or age of affected individuals.

A Waterborne Gastroenteritis Outbreak Caused by a GII Norovirus in a Holiday Camp in Catalonia (Spain), 2017

On 2 February 2017, Epidemiological Surveillance Services were notified of an outbreak of acute gastroenteritis (AGE) among schoolchildren who had taken part of a school trip from 30 January to 3 February 2017 at a holiday camp in Catalonia. A retrospective cohort study was performed to identify the causative agent, estimate the magnitude of the outbreak and identify its source, as well as to determine the route of transmission. Data collected by standardised questionnaires identified 41 episodes of AGE among 174 individuals who attended the camp. Cases had mainly symptoms of abdominal pain (73.8%), nausea (64.3%), vomiting (54.8%), diarrhoea (45.2%) and headache (42.9%). Consumption of water was associated with gastroenteritis (crude RR: 1.72, 95%CI: 1.01–2.92; adjusted RR: 1.88, 95%CI 1.03–3.56). NoV GII was detected in faeces (5 out of 13) and water samples. Additionally, faecal indicator bacteria and protozoa were detected in water samples. The outbreak showed a high attack rate and was caused by a natural water fountain not properly treated and not monitored for safety quality. There could have been a discharge of wastewater at a point close to the fountain; however, the source of contamination of the water could not be identified. Health education may be useful to eliminate risks associated with the consumption of untreated water from natural fountains.

Inactivation of Hepatitis A Virus and Human Norovirus in Clams Subjected to Heat Treatment

Bivalve mollusk contamination by enteric viruses, especially human noroviruses (HuNoV) and hepatitis A virus (HAV), is a problem with health and economic implications. The aim of the study was the evaluation of the effect of heat treatment in clams (Tawera gayi) experimentally contaminated with HuNoV using a PMA-viability RTqPCR assay to minimize measurement of non-infectious viruses, and used HAV as a model to estimate infectivity loss. Spiked clams were immersed in water at 90°C to ensure that internal meat temperature was maintained above 90°C for at least 5 min. The treatment resulted in >3.89 ± 0.24 log10 TCID50/g reduction of infectious HAV, confirming inactivation. For HuNoV, RTqPCR assays showed log10 reductions of 2.96 ± 0.79 and 2.56 ± 0.56, for GI and GII, respectively, and the use of PMA resulted in an additional log10 reduction for GII, providing a better correlation with risk reduction. In the absence of a cell culture system which could be used to determine HuNoV infectivity reduction, a performance criteria based on PMA-RTqPCR log reduction could be used to evaluate food product safety. According to data from this study, heat treatments of clams which cause reductions >3.5 log10 for GII as measured by PMA-RTqPCR assay may be regarded as an acceptable inactivation treatment, and could be set as a performance criterion to test the effectiveness of other time-temperature inactivation processes.

Unveiling Viruses Associated with Gastroenteritis Using a Metagenomics Approach

Acute infectious gastroenteritis is an important illness worldwide, especially on children, with viruses accounting for approximately 70% of the acute cases. A high number of these cases have an unknown etiological agent and the rise of next generation sequencing technologies has opened new opportunities for viral pathogen detection and discovery. Viral metagenomics in routine clinical settings has the potential to identify unexpected or novel variants of viral pathogens that cause gastroenteritis. In this study, 124 samples from acute gastroenteritis patients from 2012–2014 previously tested negative for common gastroenteritis pathogens were pooled by age and analyzed by next generation sequencing (NGS) to elucidate unidentified viral infections. The most abundant sequences detected potentially associated to acute gastroenteritis were from Astroviridae and Caliciviridae families, with the detection of norovirus GIV and sapoviruses. Lower number of contigs associated to rotaviruses were detected. As expected, other viruses that may be associated to gastroenteritis but also produce persistent infections in the gut were identified including several Picornaviridae members (EV, parechoviruses, cardioviruses) and adenoviruses. According to the sequencing data, astroviruses, sapoviruses and NoV GIV should be added to the list of viral pathogens screened in routine clinical analysis.

Detection of Norovirus in Saliva Samples from Acute Gastroenteritis Cases and Asymptomatic Subjects: Association with Age and Higher Shedding in Stool

Norovirus infections are a leading cause of acute gastroenteritis outbreaks worldwide and across all age groups, with two main genogroups (GI and GII) infecting humans. The aim of our study was to investigate the occurrence of norovirus in saliva samples from individuals involved in outbreaks of acute gastroenteritis in closed and semiclosed institutions, and its relationship with the virus strain, virus shedding in stool, the occurrence of symptoms, age, and the secretor status of the individual. Epidemiological and clinical information was gathered from norovirus outbreaks occurring in Catalonia, Spain during 2017–2018, and stool and saliva samples were collected from affected and exposed resident individuals and workers. A total of 347 saliva specimens from 25 outbreaks were analyzed. Further, 84% of individuals also provided a paired stool sample. For GII infections, norovirus was detected in 17.9% of saliva samples from symptomatic cases and 5.2% of asymptomatic individuals. Positivity in saliva occurred in both secretors and nonsecretors. None of the individuals infected by norovirus GI was positive for the virus in saliva. Saliva positivity did not correlate with any of the studied symptoms but did correlate with age ≥ 65 years old. Individuals who were positive in saliva showed higher levels of virus shedding in stool. Mean viral load in positive saliva was 3.16 ± 1.08 log₁₀ genome copies/mL, and the predominance of encapsidated genomes was confirmed by propidium monoazide (PMA)xx-viability RTqPCR assay. The detection of norovirus in saliva raises the possibility of oral-to-oral norovirus transmission during the symptomatic phase and, although to a lesser extent, even in cases of asymptomatic infections.

Effectiveness of Consumers Washing with Sanitizers to Reduce Human Norovirus on Mixed Salad

Human norovirus (HuNoV) is a foremost cause of domestically acquired foodborne acute gastroenteritis and outbreaks. Despite industrial efforts to control HuNoV contamination of foods, its prevalence in foodstuffs at retail is significant. HuNoV infections are often associated with the consumption of contaminated produce, including ready-to-eat (RTE) salads. Decontamination of produce by washing with disinfectants is a consumer habit which could significantly contribute to mitigate the risk of infection. The aim of our study was to measure the effectiveness of chemical sanitizers in inactivating genogroup I and II HuNoV strains on mixed salads using a propidium monoazide (PMAxx)-viability RTqPCR assay. Addition of sodium hypochlorite, peracetic acid, or chlorine dioxide significantly enhanced viral removal as compared with water alone. Peracetic acid provided the highest effectiveness, with log10 reductions on virus levels of 3.66 ± 0.40 and 3.33 ± 0.19 for genogroup I and II, respectively. Chlorine dioxide showed lower disinfection efficiency. Our results provide information useful to the food industry and final consumers for improving the microbiological safety of fresh products in relation to foodborne viruses.

The coordinating role of the human norovirus minor capsid protein VP2 is essential to functional change and nuclear localization of the major capsid protein VP1

Global outbreaks of norovirus (NOV) gastroenteritis are associated with the most prevalent genotype, GII.4. Mutations in the protruding domain 2 (P2 domain) of the norovirus major capsid protein (VP1) result in the emergence of various NOV variants, however, it is unclear whether the minor capsid protein (VP2) also affects the generation of VP1 variants. In this study, using a human 293T expression system, we investigated the interactions of VP1 and VP2 of three GII.4 strains, focusing on the changes in expression and cellular localization. We found that co-transfection with VP1 and VP2 leads to a significant increase in expression of both proteins compared to that in cells transfected with VP1 or VP2 alone. In contrast to VP1 expressed in the absence of VP2, which was dispersed throughout the cytosol, VP2 expressed in the absence of VP1 was found to be located in the nucleus. This could be attributed to a predicted specific nuclear localization signal found in this gene. When both proteins were expressed, VP1 was found together with VP2 in the nucleus. These results thus suggest that the VP2 of GII.4 NOVs affects the function and cellular location of VP1 and that, with the cooperation of VP2, VP1 could play a critical role in affecting cell functions by impairing the downstream transcriptional signaling and chromatin remodeling in the cell nuclei.

Characterization of intra- and inter-host norovirus P2 genetic variability in linked individuals by amplicon sequencing

Noroviruses are the main cause of epidemics of acute gastroenteritis at a global scale. Although chronically infected immunocompromised individuals are regarded as potential reservoirs for the emergence of new viral variants, viral quasispecies distribution and evolution patterns in acute symptomatic and asymptomatic infections has not been extensively studied. Amplicons of 450 nts from the P2 coding capsid domain were studied using next-generation sequencing (454/GS-Junior) platform. Inter-host diversity between symptomatic and asymptomatic acutely infected individuals linked to the same outbreak as well as their viral intra-host diversity over time were characterized. With an average of 2848 reads per sample and a cutoff frequency of 0.1%, minor variant haplotypes were detected in 5 out of 8 specimens. Transmitted variants could not be confirmed in all infected individuals in one outbreak. The observed initial intra-host viral diversity in asymptomatically infected subjects was higher than in symptomatic ones. Viral quasispecies evolution over time within individuals was host-specific, with an average of 2.8 nt changes per day (0.0062 changes per nucleotide per day) in a given symptomatic case. Nucleotide polymorphisms were detected in 28 out of 450 analyzed nucleotide positions, 32.14% of which were synonymous and 67.86% were non-synonymous. Most observed amino acid changes emerged at or near blockade epitopes A, B, D and E. Our results suggest that acutely infected individuals, even in the absence of symptoms, which go underreported and may enhance transmission, may contribute to norovirus genetic variability and evolution.

Molecular screening of blue mussels indicated high mid-summer prevalence of human genogroup II Noroviruses, including the pandemic "GII.4 2012" variants in UK coastal waters during 2013

This molecular study is the first report, to the best of our knowledge, on identification of norovirus, NoV GII.4 Sydney 2012 variants, from blue mussels collected from UK coastal waters. Blue mussels (three pooled samples from twelve mussels) collected during the 2013 summer months from UK coastal sites were screened by RT-PCR assays. PCR products of RdRP gene for noroviruses were purified, sequenced and subjected to phylogenetic analysis. All the samples tested positive for NoVs. Sequencing revealed that the NoV partial RdRP gene sequences from two pooled samples clustered with the pandemic "GII.4 Sydney variants" whilst the other pooled sample clustered with the NoV GII.2 variants. This molecular study indicated mussel contamination with pathogenic NoVs even during mid-summer in UK coastal waters which posed potential risk of NoV outbreaks irrespective of season. As the detection of Sydney 2012 NoV from our preliminary study of natural coastal mussels interestingly corroborated with NoV outbreaks in nearby areas during the same period, it emphasizes the importance of environmental surveillance work for forecast of high risk zones of NoV outbreaks.

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.

Norovirus shedding among food and healthcare workers exposed to the virus in outbreak settings

BACKGROUND

Noroviruses (NoV) are highly contagious and the leading cause of nonbacterial outbreaks of gastroenteritis worldwide. Individuals who are infected asymptomatically may act as reservoirs and facilitate the transmission of NoV, but the likelihood of workers of becoming infected in outbreak settings has not been systematically studied.

OBJECTIVES

We evaluated the occurrence of norovirus infections among workers exposed to the virus in different outbreak settings.

STUDY DESIGN

We screened feces from food handlers and healthcare workers related with gastroenteritis outbreaks, and shedding concentrations over time were calculated from serial samples of infected individuals. Sequence analyses of the capsid P2 domain and region C were used to evaluate linkage between asymptomatic employees and outbreak cases.

RESULTS

Of all employees, 59.1% were positive for NoV, and more than 70% of them were asymptomatic. Asymptomatic infections were significantly more frequent in foodborne compared to person-to-person transmitted outbreaks; and in restaurants and hotels, compared to nursing homes and healthcare institutions. Mean viral loads were similar between symptomatic and asymptomatic individuals, starting at 7.51±1.80 and 6.49±1.93 log10 genome copies/g, respectively, and decreasing to 5.28±0.76 and 4.52±1.45 log10 genome copies/g after 19days.

CONCLUSIONS

The likelihood of becoming infected when a NoV outbreak occurs at the work place is high and similar between food handlers and healthcare workers, but asymptomatic infections are more frequently identified among food handlers. Since shed amounts of viruses in the absence of symptoms are also high, reinforcement of hygiene practices among workers is especially relevant to reduce the risk of virus secondary transmissions.

Foodborne viruses

Among the wide variety of viral agents liable to be found as food contaminants, noroviruses and hepatitis A virus are responsible for most well characterized foodborne virus outbreaks. Additionally, hepatitis E virus has emerged as a potential zoonotic threat. Molecular methods, including an ISO standard, are available for norovirus and hepatitis A virus detection in foodstuffs, although the significance of genome copy detection with regard to the associated health risk is yet to be determined through viability assays. More precise and rapid methods for early foodborne outbreak investigation are being developed and they will need to be validated versus the ISO standard. In addition, protocols for next-generation sequencing characterization of outbreak-related samples must be developed, harmonized and validated as well.

Comparative genome analysis of a norovirus GII.4 strain GZ2013-L10 isolated from South China

In this study, the genome sequence of a norovirus GII.4 strain isolated from South China was comparatively analyzed. The RNA genome of the strain GZ2013-L10 was composed of 7513 nucleotides. Phylogenetic analyses based on three ORFs confirmed its genotype as GII.Pe/GII.4-2012. Compared with other 22 genomes of the same variant, nine distinct nucleotide substitutions were found in the new genome, which resulted in three amino acid changes. All 138 capsid protein VP1 sequences of GII.4-2012 variants were also collected, and multiple alignments revealed 35 variable codons. Evolutionary analyses of GII.4-2012 variants were performed against previous pandemic GII.4 variants, and 2 distinctive changes were identified on epitopes A and E (E368, T413), which resulted in an obvious variation of their solvent-accessible surface areas. Therefore, the genome of GZ2013-L10 was extensively characterized, and new emerging variations on viral epitopes were predicted to contribute to NoV persistence in humans.

The impact of calicivirus mixed infection in an oyster-associated outbreak during a food festival

BACKGROUND

Despite calicivirus food-borne outbreaks posing major public health concern worldwide, little information is at present available about the impact of caliciviruses mixed infection in an oyster-associated outbreak in China.

OBJECTIVES

To investigate the clinical and epidemiologic characteristics of an oyster-associated calicivirus outbreak initiated by a food festival in Shanghai, China, in April 2014.

STUDY DESIGN

Molecular epidemiological studies based on nucleotide sequencing and phylogenetic analysis of calicivirus strains from patients.

RESULTS

A total of 65 of the 78 (83%) cases from this outbreak were associated with raw oyster consumption. Forty-six calicivirus strains were identified from 25 stool specimens with norovirus (NoV) GII.4 Sydney_2012, GII.13, GI.2, GI.5 and sapovirus (SaV) GI.2 being predominant genotypes and with a prevalence of triple-, double- and single-infection being 20%, 48% and 28%, respectively. Meanwhile, 13 putative NoV recombinants were indicated by the phylogenetic inconsistency between capsid and polymerase genotype, mainly including GII.Pe/GII.4 Sydney_2012. Molecular epidemiological investigation showed possible multiple route transmission in the field. The clinical and epidemiologic characteristics of the mixed point-source calicivirus outbreak also conformed to Kaplan's criteria.

CONCLUSIONS

This is the first reported oyster-associated calicivirus outbreak with a high prevalence of mixed infection during a food festival described in China. Our investigation underscores the importance of early surveillance and comprehensive etiologic identification of mixed point-source outbreaks and the need for reliable standards of monitoring oysters to prevent and control calicivirus food-borne outbreaks in China.