Series of Norovirus Outbreaks Caused by Consumption of Green Coral Lettuce, Denmark, April 2016

Improving the Detection and Understanding of Infectious Human Norovirus in Food and Water Matrices: A Review of Methods and Emerging Models

Human norovirus (HuNoV) is a leading global cause of viral gastroenteritis, contributing to numerous outbreaks and illnesses annually. However, conventional cell culture systems cannot support the cultivation of infectious HuNoV, making its detection and study in food and water matrices particularly challenging. Recent advancements in HuNoV research, including the emergence of models such as human intestinal enteroids (HIEs) and zebrafish larvae/embryo, have significantly enhanced our understanding of HuNoV pathogenesis. This review provides an overview of current methods employed for HuNoV detection in food and water, along with their associated limitations. Furthermore, it explores the potential applications of the HIE and zebrafish larvae/embryo models in detecting infectious HuNoV within food and water matrices. Finally, this review also highlights the need for further optimization and exploration of these models and detection methods to improve our understanding of HuNoV and its presence in different matrices, ultimately contributing to improved intervention strategies and public health outcomes.

Microbiological hazards associated with the use of water in the post-harvest handling and processing operations of fresh and frozen fruits, vegetables and herbs (ffFVHs). Part 1 (outbreak data analysis, literature review and stakeholder questionnaire)

The contamination of water used in post-harvest handling and processing operations of fresh and frozen fruit, vegetables and herbs (ffFVHs) is a global concern. The most relevant microbial hazards associated with this water are: Listeria monocytogenes, Salmonella spp., human pathogenic Escherichia coli and enteric viruses, which have been linked to multiple outbreaks associated with ffFVHs in the European Union (EU). Contamination (i.e. the accumulation of microbiological hazards) of the process water during post-harvest handling and processing operations is affected by several factors including: the type and contamination of the FVHs being processed, duration of the operation and transfer of microorganisms from the product to the water and vice versa, etc. For food business operators (FBOp), it is important to maintain the microbiological quality of the process water to assure the safety of ffFVHs. Good manufacturing practices (GMP) and good hygienic practices (GHP) related to a water management plan and the implementation of a water management system are critical to maintain the microbiological quality of the process water. Identified hygienic practices include technical maintenance of infrastructure, training of staff and cooling of post-harvest process water. Intervention strategies (e.g. use of water disinfection treatments and water replenishment) have been suggested to maintain the microbiological quality of process water. Chlorine-based disinfectants and peroxyacetic acid have been reported as common water disinfection treatments. However, given current practices in the EU, evidence of their efficacy under industrial conditions is only available for chlorine-based disinfectants. The use of water disinfection treatments must be undertaken following an appropriate water management strategy including validation, operational monitoring and verification. During operational monitoring, real-time information on process parameters related to the process and product, as well as the water and water disinfection treatment(s) are necessary. More specific guidance for FBOp on the validation, operational monitoring and verification is needed.

Norovirus transmission mitigation strategies during simulated produce harvest and packing

In the agricultural setting, core global food safety elements, such as hand hygiene and worker furlough, should reduce the risk of norovirus contamination on fresh produce. However, the effect of these practices has not been characterized. Using a quantitative microbial risk model, we evaluated the individual and combined effect of farm-based hand hygiene and worker furlough practices on the maximum risk of norovirus infection from three produce commodities (open leaf lettuce, vine tomatoes, and raspberries). Specifically, we tested two scenarios where a harvester's and packer's norovirus infection status was: 1) assumed positive; or 2) assigned based on community norovirus prevalence estimates. In the first scenario with a norovirus-positive harvester and packer, none of the individual interventions modeled reduced produce contamination to below the norovirus infectious dose. However, combined interventions, particularly high handwashing compliance (100%) and efficacy (6 log10 virus removal achieved using soap and water for 30 s), reduced produce contamination to <1-82 residual virus. Translating produce contamination to maximum consumer infection risk, 100% handwashing with a 5 log10 virus removal was necessary to achieve an infection risk below the threshold of 0.032 infections per consumption event. When community-based norovirus prevalence estimates were applied to the harvester and packer, the single interventions of 100% handwashing with 3 log10 virus removal (average 0.02 infection risk per consumption event) or furlough of the packer (average 0.03 infection risk per consumption event) reduced maximum infection risk to below the 0.032 threshold for all commodities. Bundled interventions (worker furlough, 100% glove compliance, and 100% handwashing with 1-log10 virus reduction) resulted in a maximum risk of 0.02 per consumption event across all commodities. These results advance the evidence-base for global produce safety standards as effective norovirus contamination and risk mitigation strategies.

Target Affinity and Structural Analysis for a Selection of Norovirus Aptamers

Aptamers, single-stranded oligonucleotides that specifically bind a molecule with high affinity, are used as ligands in analytical and therapeutic applications. For the foodborne pathogen norovirus, multiple aptamers exist but have not been thoroughly characterized. Consequently, there is little research on aptamer-mediated assay development. This study characterized seven previously described norovirus aptamers for target affinity, structure, and potential use in extraction and detection assays. Norovirus-aptamer affinities were determined by filter retention assays using norovirus genotype (G) I.1, GI.7, GII.3, GII.4 New Orleans and GII.4 Sydney virus-like particles. Of the seven aptamers characterized, equilibrium dissociation constants for GI.7, GII.3, GII.4 New Orleans and GII.4 Sydney ranged from 71 ± 38 to 1777 ± 1021 nM. Four aptamers exhibited affinity to norovirus GII.4 strains; three aptamers additionally exhibited affinity toward GII.3 and GI.7. Aptamer affinity towards GI.1 was not observed. Aptamer structure analysis by circular dichroism (CD) spectroscopy showed that six aptamers exhibit B-DNA structure, and one aptamer displays parallel/antiparallel G-quadruplex hybrid structure. CD studies also showed that biotinylated aptamer structures were unchanged from non-biotinylated aptamers. Finally, norovirus aptamer assay feasibility was demonstrated in dot-blot and pull-down assays. This characterization of existing aptamers provides a knowledge base for future aptamer-based norovirus detection and extraction assay development and aptamer modification.

An Optimised Direct Lysis Method for Viral RNA Extraction and Detection of Foodborne Viruses on Fruits and Vegetables

Detection of norovirus (NoV) and hepatitis A virus (HAV) on fruits and vegetables using current standard methodologies can be inefficient. Method optimisation focussing on ease, rapidity and increased viral RNA recovery is needed for efficient reverse transcription (RT)-qPCR detection of viruses. A simple and quick direct lysis method for RNA extraction was optimised (method A) to achieve increased viral RNA recovery and minimised RT-qPCR inhibition by increasing the volume of lysis buffer and inclusion of pectinase, Plant RNA Isolation Aid and OneStep PCR Inhibitor Removal Kit. Method A and an internal method structurally comparable to the ISO 15216 standard (method B) were compared for their efficiencies to recover viral RNA from the process controls, mengovirus (MC₀) and murine norovirus (MNV), spiked in 13 types of fruits, vegetables, compound foods or seeds/nuts. All extracts (> 61) were also analysed for RT-qPCR inhibition and for natural contamination of NoV and HAV. The overall mean extraction efficiencies of MC₀ and MNV were 36 ± 31 and 44 ± 38%, respectively, for method A and 9 ± 16 and 5 ± 11%, respectively, for method B. Inhibition of RT-qPCR amplification of RNA from NoV genogroup (G)I, NoV GII, and HAV ranged from 5 ± 10 to 13 ± 14% for method A and 34 ± 36 to 48 ± 40% for method B. NoV GII was detected in samples of strawberries and seaweed processed by both methods. In conclusion, the new direct lysis method showed an overall better performance compared to the modified ISO 15216 standard and should be validated for implementation in analysis of viruses in foods of plant origin.

Norovirus waterborne outbreak in Chalkidiki, Greece, 2015: detection of GI.P2_GI.2 and GII.P16_GII.13 unusual strains

Noroviruses, along with rotaviruses, are among the leading causes of gastroenteritis worldwide and novel strains are periodically emerging. In August 2015, an unusual increase of gastroenteritis cases occurred in a touristic district in Kassandra peninsula, Chalkidiki, Northern Greece. Seven stool specimens from cases were tested positive for norovirus. Molecular investigation and phylogenetic analysis identified that there was co-circulation of norovirus GI.P2_GI.2 and the recombinant strain GII.P16_GII.13. A 1:1 case–control study conducted and showed that tap water consumption significantly associated with developing symptoms of gastroenteritis (odds ratio = 36.9, P = 0.018). The results of the epidemiological investigation, the co-circulation of two different norovirus strains, the information of a pipeline breakage at the water supply system before the onset of cases, and reports on flooded wells and sewage overflow, indicated the possibility of water contamination by sewage during the pipeline breakage leading to a large outbreak with a peak at 10 August and a possible secondary person-to-person transmission after the 16th of August. Norovirus GI.P2_GI.2 strains are rarely reported in Europe, while it is the first time that infection from the recombinant strain GII.P16_GII.13 is recorded in Greece.

Detection of norovirus infections in Denmark, 2011-2018

Norovirus (NoV) infections occur very frequently yet are rarely diagnosed. In Denmark, NoV infections are not under surveillance. We aimed to collect and describe existing laboratory-based NoV data. National NoV laboratory data were collected for 2011–2018, including information on patient identification number, age and sex, requesting physician, analysis date and result. We defined positive patient-episodes by using a 30-day time window and performed descriptive and time series analysis. Diagnostic methods used were assessed through a survey. We identified 15 809 patient-episodes (11%) out of 142 648 tested patients with an increasing trend, 9366 in 2011 vs. 32 260 in 2018. This corresponded with a gradual introduction of polymerase chain reaction analysis in laboratories. The highest positivity rate was in patients aged <5 years (15%) or >85 years (17%). There was a large difference in test performance over five Danish geographical regions and a marked seasonal variation with peaks from December to February. This is the first analysis of national NoV laboratory data in Denmark. A future laboratory-based surveillance system may benefit public health measures by describing trend, burden and severity of seasons and possibly pinpoint hospital outbreaks.

Foodborne and Food-Handler Norovirus Outbreaks: A Systematic Review

Norovirus (NoV) is the commonest cause of gastrointestinal disease in the United Kingdom and in many developed countries, causing diarrhea and vomiting in millions of cases worldwide annually. Transmission is most often mediated from person to person. NoV infection has, however, additionally been associated with the consumption of food, either through the consumption of food contaminated at source such as seafood, berries, and salad, or as a consequence of the foodstuff being contaminated in some way by a food handler during processing or serving. A systematic review of outbreaks attributed to NoV between January 2003 and July 2017 was conducted to assess the contribution of food handlers to the burden of NoV, and to identify foods commonly associated with NoV outbreaks. A total of 3021 articles were screened, of which 27 met the definition of confirmed foodborne outbreaks and 47 met the criteria for definite food-handler NoV outbreaks. Of all food types, shellfish were implicated in the greatest number of definite foodborne outbreaks. Food handlers contributed to definite food-handler outbreaks involving a diverse range of foodstuffs and in a wide variety of settings, including weddings and military establishments. More genotypes of NoV were found in people who were ill than in samples from food and food handlers. The potential for both food products and food handlers to contribute to the burden of NoV infection is demonstrated conclusively.

Epidemiology of Foodborne Norovirus Outbreaks - United States, 2009-2015

Noroviruses are the leading cause of acute gastroenteritis and foodborne disease in the United States (U.S.). About 1 in 5 reported norovirus outbreaks are spread through foodborne transmission, presenting opportunities for prevention. We describe the epidemiology of U.S. foodborne norovirus outbreaks reported to national surveillance systems, including differences between genotypes. Foodborne outbreaks that occurred during August 2009-July 2015 with norovirus reported as a single confirmed etiology to the National Outbreak Reporting System (NORS) were matched with outbreaks reported to CaliciNet, a U.S. laboratory norovirus outbreak surveillance network. We analyzed these matched outbreaks stratified by genotype for epidemiologic characteristics, including setting, size and duration, health outcomes of case-patients, implicated food, and outbreak contributing factors. Four hundred ninety-three confirmed foodborne norovirus outbreaks were reported in both NORS and CaliciNet. The most common norovirus genotypes reported were GII.4 (52%), GII.6 (9%), and GI.3 (8%). Compared to non-GII.4 outbreaks, GII.4 outbreaks had higher hospitalization rates (12.8 vs. 4.8 per 1,000 cases, P < 0.01). While contaminated foods were identified and reported in only 35% of outbreaks, molluscan shellfish (4% overall) were more often implicated in non-GII.4 outbreaks than in GII.4 outbreaks (7% vs. 1%, P = 0.04). Of the 240 outbreaks reporting at least one contributing factor, food workers were implicated as the source of contamination in 182 (76%), with no difference between GII.4 and non-GII.4 (73% vs 79%, P = 0.3). Foodborne norovirus outbreaks are frequently reported in the U.S., most of which are caused by GII.4 noroviruses. Viruses of this genotype are associated with higher rates of hospitalization; non-GII.4 noroviruses are more frequently associated with contaminated molluscan shellfish. These surveillance data highlight the diversity of noroviruses causing foodborne disease and can help guide appropriate food safety interventions, including worker hygiene, improved food handling and preparation, and further development of norovirus vaccines.

Molecular epidemiology of human adenovirus infections in Denmark, 2011-2016

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We developed new primers to improve genotyping of HAdV D.

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Six out of seven HAdV species from at least 13 HAdV types were identified.

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Young children (<5 years old) were more likely to be positive for HAdV.

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Co-infections with other gastrointestinal or respiratory viruses were common.

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A HAdV surveillance system is required to monitor circulating species and types.

Background

Human adenoviruses (HAdVs) can cause respiratory tract infections, conjunctivitis, diarrhoea and outbreaks have been reported. However, little is known about the disease burden and the molecular epidemiology of HAdV.

Objectives

To retrospectively perform a molecular characterization of HAdV positive samples received at Statens Serum Institut during the period 2011–2016 and to compare this with demographic information, geographic location, sample collection date and type and co-infection with other viral pathogens.

Study design

152 HAdV positive samples were genotyped by Sanger sequencing of a fragment of the hexon gene using published primers along with a newly developed primer set for enhanced genotyping of HAdV D. Phylogenetic analysis was used for genotyping and genotypes were compared with epidemiological information. In addition, HAdV burden and co-infection was evaluated for samples tested in laboratory analysis packages.

Results

Six out of seven HAdV species were identified and represented by 13 types. Young children (<5 years old) were more likely to be positive for HAdV and co-infections with other gastrointestinal or respiratory viruses were common. Possible outbreaks of ocular infections due to HAdV D could not be confirmed.

Conclusion

A diverse set of HAdV species were circulating in Denmark in the study period and although possible transmission clusters were identified, this could not be verified with current genotyping methods Young children were commonly affected by HAdV infection and co-infections with other viral pathogens were frequent suggesting a possible underestimation of the real HAdV burden.

[Serial Food Poisoning Outbreaks Caused by Norovirus-Contaminated Shredded Dried Laver Seaweed Provided at School Lunch, Tokyo, 2017]

In February 2017, four food poisoning outbreaks occurred in Tokyo, involving ten schools. Shredded dried laver seaweed processed by a single food manufacturer in December 2016 was provided in common for the school meals that caused all four outbreaks. Of 4,209 persons exposed, 1,193 (28.3%) had symptoms of gastroenteritis. Norovirus (NoV) GII was detected in 207 (78.1%) of 265 cases by real-time RT-PCR. Thirty-one shredded dried laver seaweed samples were examined and seven (22.6%) of them were positive for NoV GII. PCR fragments of NoV ORF1/2 junction region (302 bp) from seven shredded dried laver seaweed samples and 20 clinical samples derived from the four outbreaks were sequenced. All of them displayed complete homology, and the genotype was classified as GII.17. A nearly full-length sequence (7,420 bp) of NoV RNA derived from a case was obtained by next-generation sequencer analysis and phylogenetic analysis indicated that this strain belongs to the same cluster as Hu/GII/JP/2015/GII.P17_GII.17/Kawasaki308. Thus, our investigation elucidated that the causative agent of these four serial food poisoning outbreaks was NoV GII.17 and the infectious source was a single batch of shredded dried laver seaweed. The water activity of the shredded dried laver seaweed was found to be 0.119 to 0.129. It was epidemiologically clarified that NoV does not lose infectivity for about two months even in the dry state. We conclude that a large diffuse outbreak of food poisoning caused by NoV GII.17 contamination of shredded dried laver seaweed had occurred in Tokyo. Our elucidation of the causative agent indicated that the food poisoning outbreaks in multiple areas of Japan, including Tokyo, during January to February 2017 were caused by the same contaminated food.

Inactivation of Human Norovirus Genogroups I and II and Surrogates by Free Chlorine in Postharvest Leafy Green Wash Water

Human noroviruses (hNoVs) are a known public health concern associated with the consumption of leafy green vegetables. While a number of studies have investigated pathogen reduction on the surfaces of leafy greens during the postharvest washing process, there remains a paucity of data on the level of treatment needed to inactivate viruses in the wash water, which is critical for preventing cross-contamination. The objective of this study was to quantify the susceptibility of hNoV genotype I (GI), hNoV GII, murine norovirus (MNV), and bacteriophage MS2 to free chlorine in whole leaf, chopped romaine, and shredded iceberg lettuce industrial leafy green wash waters, each sampled three times over a 4-month period. A suite of kinetic inactivation models was fit to the viral reduction data to aid in quantification of concentration-time (CT) values. Results indicate that 3-log10 infectivity reduction was achieved at CT values of less than 0.2 mg · min/liter for MNV and 2.5 mg · min/liter for MS2 in all wash water types. CT values for 2-log10 molecular reduction of hNoV GI in whole leaf and chopped romaine wash waters were 1.5 and 0.9 mg · min/liter, respectively. For hNoV GII, CT values were 13.0 and 7.5 mg · min/liter, respectively. In shredded iceberg wash water, 3-log10 molecular reduction was not observed for any virus over the time course of experiments. These findings demonstrate that noroviruses may exhibit genogroup-dependent resistance to free chlorine and emphasize the importance of distinguishing between genogroups in hNoV persistence studies.IMPORTANCE Postharvest washing of millions of pounds of leafy greens is performed daily in industrial processing facilities with the intention of removing dirt, debris, and pathogenic microorganisms prior to packaging. Modest inactivation of pathogenic microorganisms (less than 2 log10) is known to occur on the surfaces of leafy greens during washing. Therefore, the primary purpose of the sanitizing agent is to maintain microbial quality of postharvest processing water in order to limit cross-contamination. This study modeled viral inactivation data and quantified the free-chlorine CT values that processing facilities must meet in order to achieve the desired level of hNoV GI and GII reduction. Disinfection experiments were conducted in industrial leafy green wash water collected from a full-scale fresh produce processing facility in the United States, and hNoV GI and GII results were compared with surrogate molecular and infectivity data.