Aerosolization of a Human Norovirus Surrogate, Bacteriophage MS2, during Simulated Vomiting

Aerosol Transmission of Norovirus

Norovirus (NoV) is a major cause of acute gastroenteritis outbreaks worldwide. A comprehensive understanding of the transmission mode is of great significance for the prevention and control of the NoV infection. Currently, the transmission modes of NoV include contact, food-borne, water-borne and aerosol transmission. The first three modes are more common, while aerosol transmission is seldom reported. In this paper, the source, generation mechanism, infectivity, sampling and related outbreaks of NoV aerosol are summarized and discussed.

Ultraviolet germicidal irradiation: A prediction model to estimate UV-C-induced infectivity loss in single-strand RNA viruses

Ultraviolet germicidal irradiation (UVGI) disinfection technology is effective in inactivating microorganisms. However, its performance can vary against different microorganisms due to their diverse structural and genomic features. Thus, rapid predictions of UV (254 nm) inactivation kinetics are essential, particularly for highly infectious emerging pathogens, such as SARS-CoV-2, during the extemporary COVID-19 pandemic. In this study, aiming at single-strand RNA (ssRNA) viruses, an improved genomic model was introduced to predict the UV inactivation kinetics of viral genomes using genome sequence data. First, the overall virus infectivity loss in an aqueous matrix was estimated as the sum of damage to both the entire genome and the protein capsid. Then, the "UV rate constant ratio of aerosol and liquid" was used to convert the UV rate constant for viruses in a liquid-based matrix to an airborne state. The prediction model underwent both quantitative and qualitative validation using experimental data from this study and the literature. Finally, with the goal of mitigating potential airborne transmission of ssRNA viruses in indoor environments, this paper summarizes existing in-duct UVGI system designs and evaluates their germicidal performance. The prediction model may serve as a preliminary tool to assess the effectiveness of a UVGI system for emerging or unculturable viruses or to estimate the required UV dose when designing such a system.

Valence-driven colorimetric detection of norovirus protease via peptide-AuNP interactions

We report here a colorimetric method for rapid detection of norovirus based on the valence-driven peptide-AuNP interactions. We engineered a peptide sequence named K1 with a cleavage sequence in between two lysine residues. The positively charged lysine groups aggregated the negatively charged nanoparticles leading to a purple color change. There was a red color when the cleavage sequence was digested by the Southampton norovirus 3C-like protease (SV3CP)-a protease involved in the life cycle of Human norovirus (HNV). The limit of detection was determined to be 320 nM in Tris buffer. We further show that the sensor has good performance in exhaled breath condensate, urine, and faecal matter. This research provides a potential easy and quick way to selectively detect HNV.

An approach to zwitterionic peptide design for colorimetric detection of the Southampton norovirus SV3CP protease

Noroviruses are highly contagious and are one of the leading causes of acute gastroenteritis worldwide. Due to a lack of effective antiviral therapies, there is a need to diagnose and surveil norovirus infections to implement quarantine protocols and prevent large outbreaks. Currently, the gold standard of diagnosis uses reverse transcription polymerase chain reaction (RT-PCR), but PCR can have limited availability. Here, we propose a combination of a tunable peptide substrate and gold nanoparticles (AuNPs) to colorimetrically detect the Southampton norovirus 3C-like protease (SV3CP), a key protease in viral replication. Careful design of the substrate employs a zwitterionic peptide with opposite charged moieties on the C- and N- termini to induce a rapid color change visible to the naked eye; thus, this color change is indicative of SV3CP activity. This work expands on existing zwitterionic peptide strategies for protease detection by systematically evaluating the effects of lysine and arginine on nanoparticle charge screening. We also determine a limit of detection for SV3CP of 28.0 nM with comparable results in external breath condensate, urine, and fecal matter for 100 nM of SV3CP. The key advantage of this system is its simplicity and accessibility, thus making it an attractive tool for qualitative point-of-care diagnostics.

Evaluation of aerosols in a simulated orthodontic debanding procedure

Dental practitioners may be at risk for exposure to severe acute respiratory syndrome corona virus 2 when performing aerosol generating procedures. Though recent evidence suggests that coronavirus may be transmitted through aerosol generating procedures, it is unknown whether common procedures performed in dental clinics generate aerosol. The aim of this study was to simultaneously quantify airborne concentrations of the bacteriophage MS2 near the oral cavity of a dental mannequin and behind personal protective equipment (i.e., face shield) of the practitioner during a simulated orthodontic debanding procedure. A deband was performed eight times on a dental mannequin. Optical particle counters and SKC Biosamplers were used to measure particle concentration and to collect virus aerosol generated during the procedure, both near the oral cavity and behind the orthodontists face shield. A plaque assay was used to determine the viable virus airborne concentration. When comparing the two measuring locations, near the oral cavity and behind the clinician's face shield, there was no statistically significant difference of virus concentrations or particle size distribution. This study suggests that debanding under these conditions generates live virus aerosol and a face shield does not provide increased protection from virus aerosol, but does provide some protection against splatter during the procedure.

Mechanism and potential treatments for gastrointestinal dysfunction in patients with COVID-19

The global coronavirus disease 2019 (COVID-19) has become one of the biggest threats to the world since 2019. The respiratory and gastrointestinal tracts are the main targets for severe acute respiratory syndrome coronavirus 2 infection for they highly express angiotensin-converting enzyme-2 and transmembrane protease serine 2. In patients suffering from COVID-19, gastrointestinal symptoms have ranged from 12% to 61%. Anorexia, nausea and/or vomiting, diarrhea, and abdominal pain are considered to be the main gastrointestinal symptoms of COVID-19. It has been reported that the direct damage of intestinal mucosal epithelial cells, malnutrition, and intestinal flora disorders are involved in COVID-19. However, the underlying mechanisms remain unclear. Thus, in this study, we reviewed and discussed the correlated mechanisms that cause gastrointestinal symptoms in order to help to develop the treatment strategy and build an appropriate guideline for medical workers.

Antimicrobial properties of a multi-component alloy

High traffic touch surfaces such as doorknobs, countertops, and handrails can be transmission points for the spread of pathogens, emphasizing the need to develop materials that actively self-sanitize. Metals are frequently used for these surfaces due to their durability, but many metals also possess antimicrobial properties which function through a variety of mechanisms. This work investigates metallic alloys comprised of several metals which individually possess antimicrobial properties, with the target of achieving broad-spectrum, rapid sanitation through synergistic activity. An entropy-motivated stabilization paradigm is proposed to prepare scalable alloys of copper, silver, nickel and cobalt. Using combinatorial sputtering, thin-film alloys were prepared on 100 mm wafers with ≈50% compositional grading of each element across the wafer. The films were then annealed and investigated for alloy stability. Antimicrobial activity testing was performed on both the as-grown alloys and the annealed films using four microorganisms-Phi6, MS2, Bacillus subtilis and Escherichia coli-as surrogates for human viral and bacterial pathogens. Testing showed that after 30 s of contact with some of the test alloys, Phi6, an enveloped, single-stranded RNA bacteriophage that serves as a SARS-CoV-2 surrogate, was reduced up to 6.9 orders of magnitude (> 99.9999%). Additionally, the non-enveloped, double-stranded DNA bacteriophage MS2, and the Gram-negative E. coli and Gram-positive B. subtilis bacterial strains showed a 5.0, 6.4, and 5.7 log reduction in activity after 30, 20 and 10 min, respectively. Antimicrobial activity in the alloy samples showed a strong dependence on the composition, with the log reduction scaling directly with the Cu content. Concentration of Cu by phase separation after annealing improved activity in some of the samples. The results motivate a variety of themes which can be leveraged to design ideal antimicrobial surfaces.

Illuminating Human Norovirus: A Perspective on Disinfection of Water and Surfaces Using UVC, Norovirus Model Organisms, and Radiation Safety Considerations

Human noroviruses (HuNoVs) are a major cause of gastroenteritis and are associated with high morbidity because of their ability to survive in the environment and small inoculum size required for infection. Norovirus is transmitted through water, food, high touch-surfaces, and human-to-human contact. Ultraviolet Subtype C (UVC) light-emitting diodes (LEDs) can disrupt the norovirus transmission chain for water, food, and surfaces. Here, we illuminate considerations to be adhered to when picking norovirus surrogates for disinfection studies and shine light on effective use of UVC for norovirus infection control in water and air and validation for such systems and explore the blind spot of radiation safety considerations when using UVC disinfection strategies. This perspective also discusses the promise of UVC for norovirus mitigation to save and ease life.

Review on inactivation of airborne viruses using non-thermal plasma technologies: from MS2 to coronavirus

Although several non-thermal plasmas (NTPs) technologies have been widely investigated in air treatment, very few studies have focused on the inactivation mechanism of viruses by NTPs. Due to its efficiency and environmental compatibility, non-thermal plasma could be considered a promising virus-inactivation technology. Plasma is a partly or fully ionized gas including some species (i.e., electrons, free radicals, ions, and neutral molecules) to oxidize pollutants or inactivate harmful organisms. Non-thermal plasmas are made using less energy and have an active electron at a much higher temperature than bulk gas molecules. This review describes NTPs for virus inactivation in indoor air. The different application processes of plasma for microorganism inactivation at both laboratory and pilot-scale was also reviewed This paper reports on recent advances in this exciting area of viral inactivation identifying applications and mechanisms of inactivation, and summarizing the results of the latest experiments in the literature. Moreover, special attention was paid to the mechanism of virus inactivation. Finally, the paper suggests research directions in the field of airborne virus inactivation using non-thermal plasma.

Determination of murine norovirus aerosol concentration during toilet flushing

Murine norovirus (MNV) was used as a surrogate for human viral pathogens (e.g., norovirus) to determine if toilet flushing resulted in the aerosolization of virus. A flushometer type toilet was seeded with a viral solution of 105 and 106 PFU mL-1 of MNV and then flushed. Upon flushing, two bioaerosol samplers were activated to collect aerosolized MNV. Prior to the experiment, two optical particle counters monitored particle size and number distribution of aerosol produced from flushing a toilet across height, position, and side. The location with the highest mean particle concentration, was behind the toilet and 0.15 m above the toilet bowl rim, which is where bioaerosol sampling occurred. Bioaerosol and toilet water samples were collected, extracted and then quantified using RT-ddPCR. The concentration of MNV collected after seeding the toilet water ranged from 2.18 × 105 to 9.65 × 106 total copies of MNV. Positive samples of airborne MNV were detected with collected concentrations ranging from 383 to 684 RNA copies/m3 of air. This study provides evidence that viral pathogens may be aerosolized when a toilet is flushed. Furthermore, the MNV used in this study is a model organism for human norovirus and may be generalizable to other viral pathogens (e.g., coronavirus). This study suggests that virus is aerosolized from toilet flushing and may contribute to human exposure to viral pathogens.

Marijuana toxicosis in dogs in Melbourne, Australia, following suspected ingestion of human faeces: 15 cases (2011-2020)

This retrospective case series describes a novel and unexpected source for marijuana toxicosis in dogs; suspected ingestion of human faeces containing Δ⁹ -tetrahydrocannabinol (THC). Medical records from four, 24-h veterinary emergency hospitals in Melbourne, Australia, were reviewed and 15 dogs met the criteria for inclusion in this case series. Clinical signs of marijuana toxicosis included ataxia (n = 13), mydriasis (n = 6), hyperaesthesia (n = 5), urinary incontinence (n = 4) and stupor (n = 3). A urine drug screening test was performed for eight dogs and all were positive for THC. Confirmation of ingestion of human faeces was based on owner-witnessed ingestion (n = 7) or the presence of faecal material within vomit (n = 8). Sites of human faecal exposure were recorded to be a local park (n = 10), beach (n = 1), camp site (n = 1) and walking trail (n = 1). Time from exposure to development of clinical signs ranged between 3 and 6 h (n = 4). All dogs survived to discharge. Ingestion of human faeces containing THC may lead to marijuana toxicosis in dogs. Veterinary staff and owners should be attentive in regard to using appropriate hygiene measures when managing these dogs.

Detection and Quantification of Enteric Pathogens in Aerosols Near Open Wastewater Canals in Cities with Poor Sanitation

Urban sanitation infrastructure is inadequate in many low-income countries, leading to the presence of highly concentrated, uncontained fecal waste streams in densely populated areas. Combined with mechanisms of aerosolization, airborne transport of enteric microbes and their genetic material is possible in such settings but remains poorly characterized. We detected and quantified enteric pathogen-associated gene targets in aerosol samples near open wastewater canals (OWCs) or impacted (receiving sewage or wastewater) surface waters and control sites in La Paz, Bolivia; Kanpur, India; and Atlanta, USA, via multiplex reverse-transcription qPCR (37 targets) and ddPCR (13 targets). We detected a wide range of enteric targets, some not previously reported in extramural urban aerosols, with more frequent detections of all enteric targets at higher densities in La Paz and Kanpur near OWCs. We report density estimates ranging up to 4.7 × 10² gc per m_air³ across all targets including heat-stable enterotoxigenic Escherichia coli, Campylobacter jejuni, enteroinvasive E. coli/Shigella spp., Salmonella spp., norovirus, and Cryptosporidium spp. Estimated 25, 76, and 0% of samples containing positive pathogen detects were accompanied by culturable E. coli in La Paz, Kanpur, and Atlanta, respectively, suggesting potential for viability of enteric microbes at the point of sampling. Airborne transmission of enteric pathogens merits further investigation in cities with poor sanitation.

Quantitative microbial risk assessment of human norovirus infection in environmental service workers due to healthcare-associated fomites

BACKGROUND

Healthcare-associated norovirus outbreaks place a large burden on healthcare staff. Environmental service workers (ESWs), however, remain understudied despite high contact with potentially contaminated surfaces. Understanding the magnitude of the risk of norovirus infection in healthcare ESWs can protect workers and improve infection control.

AIM

This study simulated the risk of norovirus infection for unprotected ESWs after a single fomite contact, assuming no disinfection or protective equipment, in norovirus-positive patient rooms. In addition, the risk of secondary surface transmission from norovirus-exposed ESWs was simulated.

METHODS

A quantitative microbial risk assessment employing two-dimensional Monte Carlo simulation with parameters extracted from the literature was used to estimate norovirus infection from multiple fomite contact scenarios defined by: norovirus source (patient vomit/diarrhoea), location (bathroom/patient room) and target outcome (ESW/secondary illness).

FINDINGS

Unprotected ESWs have a maximum estimated risk of norovirus infection of 33% (1:3) for a single fomite contact in a room where a norovirus-positive patient had a diarrhoeal event. Patient vomit events lead to fomite contact risk estimates that are four orders of magnitude lower than those for diarrhoeal events. The estimated risk of secondary illness from touching a common surface is as high as 25% (1:4) after single fomite exposure following a diarrhoeal event.

CONCLUSIONS

A single fomite contact may lead to sizable risk of norovirus infection in ESWs if personal protective equipment and disinfection are not used appropriately. ESWs can also transfer virus to secondary surfaces, initiating further infections. Interventions are needed to reduce fomite transfer of norovirus, and protect patients and staff from nosocomial infections.

Noroviruses-The State of the Art, Nearly Fifty Years after Their Initial Discovery

Human noroviruses are recognised as the major global cause of viral gastroenteritis. Here, we provide an overview of notable advances in norovirus research and provide a short recap of the novel model systems to which much of the recent progress is owed. Significant advances include an updated classification system, the description of alternative virus-like protein morphologies and capsid dynamics, and the further elucidation of the functions and roles of various viral proteins. Important milestones include new insights into cell tropism, host and microbial attachment factors and receptors, interactions with the cellular translational apparatus, and viral egress from cells. Noroviruses have been detected in previously unrecognised hosts and detection itself is facilitated by improved analytical techniques. New potential transmission routes and/or viral reservoirs have been proposed. Recent in vivo and in vitro findings have added to the understanding of host immunity in response to norovirus infection, and vaccine development has progressed to preclinical and even clinical trial testing. Ongoing development of therapeutics includes promising direct-acting small molecules and host-factor drugs.

Recovery of Infectious Human Norovirus GII.4 Sydney From Fomites via Replication in Human Intestinal Enteroids

Contamination of fomites by human norovirus (HuNoV) can initiate and prolong outbreaks. Fomite swabbing is necessary to predict HuNoV exposure and target interventions. Historically, swab recovered HuNoV has been measured by molecular methods that detect viral RNA but not infectious HuNoV. The recent development of HuNoV cultivation in human intestinal enteroids (HIEs) enables detection of infectious HuNoV. It is unknown if the swabbing process and swab matrix will allow for cultivation of fomite recovered HuNoV. We used HIEs to culture swab-recovered HuNoV GII.4 Sydney from experimentally infected surfaces—a hospital bed tray (N = 32), door handle (N = 10), and sanitizer dispenser (N = 11). Each surface was swabbed with macrofoam swabs premoistened in PBS plus 0.02% Tween80. Swab eluate was tested for infectious HuNoV by cultivation in HIE monolayers. Infectious HuNoV can be recovered from surfaces inoculated with at least 10⁵ HuNoV genome equivalents/3 cm². In total, 57% (N = 53) of recovered swabs contained infectious HuNoV detected by HIEs. No difference in percent positive swabs was observed between the three surfaces at p = 0.2. We demonstrate that fomite swabbing can be combined with the HIE method to cultivate high titer infectious HuNoV from the environment, filling a significant gap in HuNoV detection. Currently, high titers of HuNoV are required to measure growth in HIEs and the HIE system precludes absolute quantification of infectious viruses. However, the HIE system can provide a binary indication of infectious HuNoV which enhances existing detection methods. Identification of infectious HuNoVs from swabs can increase monitoring accuracy, enhance risk estimates, and help prevent outbreaks.

COVID-19, nausea, and vomiting

Exclusion of nausea (N) and vomiting (V) from detailed consideration as symptoms of COVID-19 is surprising as N can be an early presenting symptom. We examined the incidence of NV during infection before defining potential mechanisms. We estimate that the overall incidence of nausea (median 10.5%), although variable, is comparable with diarrhea. Poor definition of N, confusion with appetite loss, and reporting of N and/or V as a single entity may contribute to reporting variability and likely underestimation. We propose that emetic mechanisms are activated by mediators released from the intestinal epithelium by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) modulate vagal afferents projecting to the brainstem and after entry into the blood, activate the area postrema (AP) also implicated in anorexia. The receptor for spike protein of SARS-CoV-2, angiotensin 2 converting enzyme (ACE2), and transmembrane protease serine (for viral entry) is expressed in upper gastrointestinal (GI) enterocytes, ACE2 is expressed on enteroendocrine cells (EECs), and SARS-CoV-2 infects enterocytes but not EECs (studies needed with native EECs). The resultant virus-induced release of epithelial mediators due to exocytosis, inflammation, and apoptosis provides the peripheral and central emetic drives. Additionally, data from SARS-CoV-2 show an increase in plasma angiotensin II (consequent on SARS-CoV-2/ACE2 interaction), a centrally (AP) acting emetic, providing a further potential mechanism in COVID-19. Viral invasion of the dorsal brainstem is also a possibility but more likely in delayed onset symptoms. Overall, greater attention must be given to nausea as an early symptom of COVID-19 and for the insights provided into the GI effects of SARS-CoV-2.

Survival of MS2 and Φ6 viruses in droplets as a function of relative humidity, pH, and salt, protein, and surfactant concentrations

The survival of viruses in droplets is known to depend on droplets' chemical composition, which may vary in respiratory fluid between individuals and over the course of disease. This relationship is also important for understanding the persistence of viruses in droplets generated from wastewater, freshwater, and seawater. We investigated the effects of salt (0, 1, and 35 g/L), protein (0, 100, and 1000 μg/mL), surfactant (0, 1, and 10 μg/mL), and droplet pH (4.0, 7.0, and 10.0) on the viability of viruses in 1-μL droplets pipetted onto polystyrene surfaces and exposed to 20%, 50%, and 80% relative humidity (RH) using a culture-based approach. Results showed that viability of MS2, a non-enveloped virus, was generally higher than that of Φ6, an enveloped virus, in droplets after 1 hour. The chemical composition of droplets greatly influenced virus viability. Specifically, the survival of MS2 was similar in droplets at different pH values, but the viability of Φ6 was significantly reduced in acidic and basic droplets compared to neutral ones. The presence of bovine serum albumin protected both MS2 and Φ6 from inactivation in droplets. The effects of sodium chloride and the surfactant sodium dodecyl sulfate varied by virus type and RH. Meanwhile, RH affected the viability of viruses as shown previously: viability was lowest at intermediate to high RH. The results demonstrate that the viability of viruses is determined by the chemical composition of carrier droplets, especially pH and protein content, and environmental factors. These findings emphasize the importance of understanding the chemical composition of carrier droplets in order to predict the persistence of viruses contained in them.

Modification of Major Contributors Responsible for Latrine Malodor on Exposure to Hypochlorous Acid: The Potential for Simultaneously Impacting Odor and Infection Hazards to Encourage Latrine Use

Open defecation remains a common practice in developing countries and leads to high incidence and prevalence of acute gastroenteritis, which is most often caused by human noroviruses (human NoV). Encouraging the use of toilets and pit latrines is one method of improving sanitation; however, it is often hindered by not only cultural traditions but also from a reluctance to use latrines and toilets due to their odor and impression of uncleanliness. In an effort to establish new means to encourage toilet and latrine use, laboratory experiments tested the ability of hypochlorous acid (HOCl) to modify the malodorous compounds identified in the air in latrines in developing countries (indole, p-cresol, dimethyl disulfide (DMDS), dimethyl trisulfide (DMTS), and butyric acid) and inactivate MS2 bacteriophage, a surrogate for human NoV. After 5 minutes, > 94% of indole, p-cresol, DMDS, and DMTS was modified as determined by high-pressure liquid chromatography in the presence of 100 ppm HOCl. A log₁₀ reduction value (LRV) greater than 6 was seen for MS2 bacteriophage after 5 minutes of exposure to 100 ppm HOCl in solution. Sensory studies indicated that there was a significant difference (P ≤ 0.05) between the untreated and HOCl-treated samples for all five malodorous compounds tested. The findings suggest that introduction of HOCl into the headspace air could encourage latrine and toilet use. Optimization of HOCl dosing in air to accomplish both odor control and reduction of infectious hazards is worthy of further study.

Survival of Human Norovirus Surrogates in Water upon Exposure to Thermal and Non-Thermal Antiviral Treatments

Human noroviruses are the leading cause of foodborne gastroenteritis worldwide and disease outbreaks have been linked to contaminated surface waters as well as to produce consumption. Noroviruses are extremely stable in water and their presence is being detected with increasing frequency, yet there are no viable methods for reducing norovirus contamination in environmental water. Despite this, there is little knowledge regarding the physical and chemical factors that influence the environmental persistence of this pathogen. This study evaluated the impact of common chemical and physical properties of surface water on the stability of murine norovirus and examined the effect of food-safe chitosan microparticles on infectivity of two human norovirus surrogates. While chemical additives had a minor impact on virus survival, chitosan microparticles significantly reduced infectious titers of both murine norovirus and MS2 bacteriophage.

Detection of Viruses from Bioaerosols Using Anion Exchange Resin

This protocol demonstrates a customized bioaerosol sampling method for viruses. In this system, anion exchange resin is coupled with liquid impingement-based air sampling devices for efficacious concentration of negatively-charged viruses from bioaerosols. Thus, the resin serves as an additional concentration step in the bioaerosol sampling workflow. Nucleic acid extraction of the viral particles is then performed directly from the anion exchange resin, with the resulting sample suitable for molecular analyses. Further, this protocol describes a custom-built bioaerosol chamber capable of generating virus-laden bioaerosols under a variety of environmental conditions and allowing for continuous monitoring of environmental variables such as temperature, humidity, wind speed, and aerosol mass concentration. The main advantage of using this protocol is increased sensitivity of viral detection, as assessed via direct comparison to an unmodified conventional liquid impinger. Other advantages include the potential to concentrate diverse negatively-charged viruses, the low cost of anion exchange resin (~$0.14 per sample), and ease of use. Disadvantages include the inability of this protocol to assess infectivity of resin-adsorbed viral particles, and potentially the need for the optimization of the liquid sampling buffer used within the impinger.

Routes of transmission of influenza A H1N1, SARS CoV, and norovirus in air cabin: Comparative analyses

Identifying the exact transmission route(s) of infectious diseases in indoor environments is a crucial step in developing effective intervention strategies. In this study, we proposed a comparative analysis approach and built a model to simulate outbreaks of 3 different in-flight infections in a similar cabin environment, that is, influenza A H1N1, severe acute respiratory syndrome (SARS) coronavirus (CoV), and norovirus. The simulation results seemed to suggest that the close contact route was probably the most significant route (contributes 70%, 95% confidence interval [CI]: 67%-72%) in the in-flight transmission of influenza A H1N1 transmission; as a result, passengers within 2 rows of the index case had a significantly higher infection risk than others in the outbreak (relative risk [RR]: 13.4, 95% CI: 1.5-121.2, P = .019). For SARS CoV, the airborne, close contact, and fomite routes contributed 21% (95% CI: 19%-23%), 29% (95% CI: 27%-31%), and 50% (95% CI: 48%-53%), respectively. For norovirus, the simulation results suggested that the fomite route played the dominant role (contributes 85%, 95% CI: 83%-87%) in most cases; as a result, passengers in aisle seats had a significantly higher infection risk than others (RR: 9.5, 95% CI: 1.2-77.4, P = .022). This work highlighted a method for using observed outbreak data to analyze the roles of different infection transmission routes.

'VIOLET': a fluorescence-based simulation exercise for training healthcare workers in the use of personal protective equipment

Background

Healthcare workers caring for patients with high-consequence infectious diseases (HCIDs) require protection from pathogen exposure, for example by wearing personal protective equipment (PPE). Protection is acquired through the inherent safety of the PPE components, but also their safe and correct use, supported by adequate training and user familiarity. However, the evidence base for HCID PPE ensembles and any associated training is lacking, with subsequent variation between healthcare providers.

Aim

To develop an evidence-based assessment and training tool for evaluating PPE ensembles and doffing protocols, in the assessment of patients with suspected HCIDs.

Methods

VIOLET (Visualising Infection with Optimised Light for Education and Training) comprises a healthcare mannequin adapted to deliver simulated bodily fluids containing UV-fluorescent tracers. On demand and remotely operated, the mannequin projectile vomits (blue), coughs (red), has diarrhoea (yellow) and is covered in sweat (orange). Wearing PPE, healthcare staff participate in an HCID risk assessment and examination of the ‘patient’, thereby becoming exposed to these bodily fluids. Contamination of PPE is visualized and body-mapped under UV light before and after removal. Observational findings and participant feedback, around its use as a training exercise, is also recorded.

Findings

Significant contamination from different exposure events was seen, enabling evaluation of PPE and doffing procedures used. Observational data and participant feedback demonstrated its strengths and success as a training technique.

Conclusion

Simulation exercises using VIOLET provide evidence-based assessment of PPE ensembles, and are a valuable resource for training of healthcare staff in wearing and safe doffing of PPE.

Comparing the performance of 3 bioaerosol samplers for influenza virus

Respiratory viral diseases can be spread when a virus-containing particle (droplet) from one individual is aerosolized and subsequently comes into either direct or indirect contact with another individual. Increasing numbers of studies are examining the occupational risk to healthcare workers due to proximity to patients. Selecting the appropriate air sampling method is a critical factor in assuring the analytical performance characteristics of a clinical study. The objective of this study was to compare the physical collection efficiency and virus collection efficiency of a 5 mL compact SKC BioSampler®, a gelatin filter, and a glass fiber filter, in a laboratory setting. The gelatin filter and the glass fiber filter were housed in a home-made filter holder. Submersion (with vortexing and subsequent centrifugation) was used for the gelatin and glass fiber filters. Swabbing method was also tested to retrieve the viruses from the glass fiber filter. Experiments were conducted using the H1N1 influenza A virus A/Puerto Rico/8/1934 (IAV-PR8), and viral recovery was determined using culture and commercial real-time-PCR (BioFire and Xpert). An atomizer was used to aerosolize a solution of influenza virus in PBS for measurement, and two Scanning Mobility Particle Sizers were used to determine particle size distributions. The SKC BioSampler demonstrated a U-shaped physical collection efficiency, lowest for particles around 30-50 nm, and highest at 10 nm and 300-350 nm within the size range examined. The physical collection efficiency of the gelatin filter was strongly influenced by air flow and time: a stable collection across all particle sizes was only observed at 2 L/min for the 9 min sampling time, otherwise, degradation of the filter was observed. The glass fiber filter demonstrated the highest physical collection efficiency (100% for all sizes) of all tested samplers, however, its overall virus recovery efficiency fared the worst (too low to quantify). The highest viral collection efficiencies for the SKC BioSampler and gelatin filter were 5% and 1.5%, respectively. Overall, the SKC BioSampler outperformed the filters. It is important to consider the total concentration of viruses entering the sampler when interpreting the results.

Contact patterns during cleaning of vomitus: A simulation study

BACKGROUND

Environmental service workers cleaning bodily fluids may transfer pathogens through the environment and to themselves through contacts.

METHODS

Participants with experience in cleaning of hospital environments were asked to clean simulated vomitus using normal practices in a simulated patient room while being videorecorded. Contacts with environmental surfaces and self were later observed.

RESULTS

In 21 experimental trials with 7 participants, environmental surfaces were contacted 26.8 times per trial, at a frequency of 266 contacts per hour, on average. Self-contact occurred in 9 of 21 trials, and involved 1-18 contacts, mostly to the upper body. The recommended protocol of cleaning bodily fluids was followed by a minority of participants (2 of 7), and was associated with fewer surface contacts, improved cleaning quality, and different tool use. Participants used different cleaning practices, but each employed similar practices each time they performed an experimental trial.

CONCLUSIONS

Training in the use of the recommended protocol may standardize cleaning practices and reduce the number of surface contacts.

An Effective Surrogate Tracer Technique for S. aureus Bioaerosols in a Mechanically Ventilated Hospital Room Replica Using Dilute Aqueous Lithium Chloride

Finding a non-pathogenic surrogate aerosol that represents the deposition of typical bioaerosols in healthcare settings is beneficial from the perspective of hospital facility testing, general infection control and outbreak analysis. This study considers aerosolization of dilute aqueous lithium chloride (LiCl) and sodium chloride (NaCl) solutions as surrogate tracers capable of representing Staphylococcus aureus bioaerosol deposition on surfaces in mechanically ventilated rooms. Tests were conducted in a biological test chamber set up as a replica hospital single patient room. Petri dishes on surfaces were used to collect the Li, Na and S. aureus aerosols separately after release. Biological samples were analyzed using cultivation techniques on solid media, and flame atomic absorption spectroscopy was used to measure Li and Na atom concentrations. Spatial deposition distribution of Li tracer correlated well with S. aureus aerosols (96% of pairs within a 95% confidence interval). In the patient hospital room replica, results show that the most contaminated areas were on surfaces 2 m away from the source. This indicates that the room’s airflow patterns play a significant role in bioaerosol transport. NaCl proved not to be sensitive to spatial deposition patterns. LiCl as a surrogate tracer for bioaerosol deposition was most reliable as it was robust to outliers, sensitive to spatial heterogeneity and found to require less replicates than the S. aureus counterpart to be in good spatial agreement with biological results.

Recipes for simulated vomitus

We developed and demonstrated the stability of recipes for simulated vomitus for use in experiments characterizing occupational exposures to body fluid during simulated healthcare activities. The recipes can be easily adapted to make other simulated bodily fluids at low costs and surrogates added to facilitate detection.

Quantitative Risk Assessment of Norovirus Transmission in Food Establishments: Evaluating the Impact of Intervention Strategies and Food Employee Behavior on the Risk Associated with Norovirus in Foods

We developed a quantitative risk assessment model using a discrete event framework to quantify and study the risk associated with norovirus transmission to consumers through food contaminated by infected food employees in a retail food setting. This study focused on the impact of ill food workers experiencing symptoms of diarrhea and vomiting and potential control measures for the transmission of norovirus to foods. The model examined the behavior of food employees regarding exclusion from work while ill and after symptom resolution and preventive measures limiting food contamination during preparation. The mean numbers of infected customers estimated for 21 scenarios were compared to the estimate for a baseline scenario representing current practices. Results show that prevention strategies examined could not prevent norovirus transmission to food when a symptomatic employee was present in the food establishment. Compliance with exclusion from work of symptomatic food employees is thus critical, with an estimated range of 75-226% of the baseline mean for full to no compliance, respectively. Results also suggest that efficient handwashing, handwashing frequency associated with gloving compliance, and elimination of contact between hands, faucets, and door handles in restrooms reduced the mean number of infected customers to 58%, 62%, and 75% of the baseline, respectively. This study provides quantitative data to evaluate the relative efficacy of policy and practices at retail to reduce norovirus illnesses and provides new insights into the interactions and interplay of prevention strategies and compliance in reducing transmission of foodborne norovirus.

Quantifying the size-resolved dynamics of indoor bioaerosol transport and control

Understanding the bioaerosol dynamics of droplets and droplet nuclei emitted during respiratory activities is important for understanding how infectious diseases are transmitted and potentially controlled. To this end, we conducted experiments to quantify the size-resolved dynamics of indoor bioaerosol transport and control in an unoccupied apartment unit operating under four different HVAC particle filtration conditions. Two model organisms (Escherichia coli K12 and bacteriophage T4) were aerosolized under alternating low and high flow rates to roughly represent constant breathing and periodic coughing. Size-resolved aerosol sampling and settle plate swabbing were conducted in multiple locations. Samples were analyzed by DNA extraction and quantitative polymerase chain reaction (qPCR). DNA from both organisms was detected during all test conditions in all air samples up to 7 m away from the source, but decreased in magnitude with the distance from the source. A greater fraction of T4 DNA was recovered from the aerosol size fractions smaller than 1 μm than E. coli K12 at all air sampling locations. Higher efficiency HVAC filtration also reduced the amount of DNA recovered in air samples and on settle plates located 3-7 m from the source.

A method for the improved detection of aerosolized influenza viruses and the male-specific (F+) RNA coliphage MS2

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Developed a method for viral bioaerosol sampling using anion exchange resin.

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MS2 and influenza viruses (A/B) detection improved by 8.26×, 6.77× and 3.33×.

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The anion exchange resin method can adapt to existing bioaerosol samplers.

The detection of aerosolized viruses can serve as an important surveillance and control tool in agriculture, human health, and environmental settings. Here, we adapted an anion exchange resin-based method, initially developed to concentrate negatively charged viruses from water, to liquid impingement-based bioaerosol sampling. In this method, aerosolized viruses are collected in a 20 ml liquid sample contained within widely used impingers, BioSamplers (SKC Inc., Eighty Four, PA), and further concentrated via adsorption to an anion exchange resin that is suspended within this liquid. Viral nucleic acids are then extracted from the resin to facilitate molecular analyses through a reduction in the effective sample volume. For this study, various quantities of two negatively charged viruses, type A and type B influenza viruses (FluMist Quadrivalent vaccine) and the male-specific (F+) RNA coliphage MS2 (MS2), were nebulized into a custom-built bioaerosolization chamber, and sampled using BioSamplers with and without anion exchange resin. Compared to direct testing of the BioSampler liquid, detection was improved by 6.77× and 3.33× for type A and type B influenza viruses, respectively, by using the anion exchange resin. For MS2, the anion exchange resin method allowed for an average improvement in detection of 8.26×.

Swab Sampling Method for the Detection of Human Norovirus on Surfaces

Human noroviruses are a leading cause of epidemic and sporadic gastroenteritis worldwide. Because most infections are either spread directly via the person-to-person route or indirectly through environmental surfaces or food, contaminated fomites and inanimate surfaces are important vehicles for the spread of the virus during norovirus outbreaks. We developed and evaluated a protocol using macrofoam swabs for the detection and typing of human noroviruses from hard surfaces. Compared with fiber-tipped swabs or antistatic wipes, macrofoam swabs allow virus recovery (range 1.2-33.6%) from toilet seat surfaces of up to 700 cm2. The protocol includes steps for the extraction of the virus from the swabs and further concentration of the viral RNA using spin columns. In total, 127 (58.5%) of 217 swab samples that had been collected from surfaces in cruise ships and long-term care facilities where norovirus gastroenteritis had been reported tested positive for GII norovirus by RT-qPCR. Of these 29 (22.8%) could be successfully genotyped. In conclusion, detection of norovirus on environmental surfaces using the protocol we developed may assist in determining the level of environmental contamination during outbreaks as well as detection of virus when clinical samples are not available; it may also facilitate monitoring of effectiveness of remediation strategies.

Capturing norovirus transmission

Human norovirus is a leading cause of gastroenteritis and is efficiently transmitted between humans and around the globe. The burden of norovirus infections in the global community and in health-care settings warrant the availability of outbreak prevention strategies and control measures that are tailored to the pathogen, outbreak setting and population at risk. A better understanding of viral and host determinants of transmission would aid in developing and fine-tuning such efforts. Here, we describe mechanisms of transmission, available model systems for studying norovirus transmission and their strengths and weaknesses as well as future research strategies.

Routes of Transmission in the Food Chain

More than 250 different foodborne diseases have been described to date, annually affecting about one-third of the world's population. The incidence of foodborne diseases has been underreported and underestimated, and the asymptomatic presentation of some of the illnesses, worldwide heterogeneities in reporting, and the alternative transmission routes of certain pathogens are among the factors that contribute to this. Globalization, centralization of the food supply, transportation of food products progressively farther from their places of origin, and the multitude of steps where contamination may occur have made it increasingly challenging to investigate foodborne and waterborne outbreaks. Certain foodborne pathogens may be transmitted directly from animals to humans, while others are transmitted through vectors, such as insects, or through food handlers, contaminated food products or food-processing surfaces, or transfer from sponges, cloths, or utensils. Additionally, the airborne route may contribute to the transmission of certain foodborne pathogens. Complicating epidemiological investigations, multiple transmission routes have been described for some foodborne pathogens. Two types of transmission barriers, primary and secondary, have been described for foodborne pathogens, each of them providing opportunities for preventing and controlling outbreaks. Primary barriers, the most effective sites of prophylactic intervention, prevent pathogen entry into the environment, while secondary barriers prevent the multiplication and dissemination of pathogens that have already entered the environment. Understanding pathogen dynamics, monitoring transmission, and implementing preventive measures are complicated by the phenomenon of superspreading, which refers to the concept that, at the level of populations, a minority of hosts is responsible for the majority of transmission events.

Partitioning of Viruses in Wastewater Systems and Potential for Aerosolization

To gain insight into the potential for aerosolization of viruses in wastewater systems, we investigated the partitioning of MS2 and Phi6 bacteriophages in synthetic sludge and anaerobically digested sludge from a wastewater treatment plant. We evaluated partitioning among the liquid, solids, and material surfaces of porcelain, concrete, polyvinyl chloride (PVC), and polypropylene. In all cases, at least 94% of the virions partitioned into the liquid fraction. In real sludge, no more than 0.8% of virions partitioned to the solids and no more than 6% to the material surface. Both MS2 and Phi6 partitioned more to the surface of concrete and polypropylene than to the surface of porcelain or PVC. Partitioning of viruses in wastewater among the liquid, biosolids, and material surface does not appear to mitigate the potential for aerosolization of virus, as most of the virus remains in the liquid phase.

Persistence of F-Specific RNA Coliphages in Surface Waters from a Produce Production Region along the Central Coast of California

F+ RNA coliphages (FRNA) are used to source-track fecal contamination and as surrogates for enteric pathogen persistence in the environment. However, the environmental persistence of FRNA is not clearly understood and necessitates the evaluation of the survival of prototype and environmental isolates of FRNA representing all four genogroups in surface waters from the central coast of California. Water temperature played a significant role in persistence-all prototype and environmental strains survived significantly longer at 10 °C compared to 25 °C. Similarly, the availability of host bacterium was found to be critical in FRNA survival. In the absence of E. coli F(amp), all prototypes of FRNA disappeared rapidly with a D-value (days for one log reduction) of <1.2 d from water samples incubated at 25 °C; the longest surviving prototype was SP. However, in the presence of the host, the order of persistence at 25 °C was QB>MS2>SP>GA and at 10 °C it was QB = MS2>GA>SP. Significant differences in survival were observed between prototypes and environmental isolates of FRNA. While most environmental isolates disappeared rapidly at 25 °C and in the absence of the host, members of genogroups GIII and GI persisted longer with the host compared to members of GII and GIV. Consequentially, FRNA based source tracking methods can be used to detect phages from recent fecal contamination along with those that persist longer in the environment as a result of cooler temperatures and increased host presence.