Prolonged outbreak of Norwalk gastroenteritis in an isolated guest house

A review of environmental contamination during outbreaks of Norwalk-like virus

Norwalk-like viruses (NLV) commonly cause outbreaks of gastroenteritis in hospitals and can result in major disruption of services. It is considered that contamination of the environment can be a cause of transmission and prolonged or recurring outbreaks. In order to control outbreaks it is important to establish the role of environmental contamination in transmission and the decontamination measures required to prevent this. A review of available evidence is described, showing that despite evidence of environmental contamination with NLV during outbreaks, its presence remains unproven as a cause of prolonged or recurring outbreaks. Evidence suggests that the virus might survive for at least 12 days in carpets and 21-28 days in a dried state at room temperature. NLV has been detected from swabs taken from a variety of sources, including lockers, commodes, toilets, door handles, soft furnishings, frequently handled items and horizontal surfaces below and above 1.5 metres. Expert opinion suggests that carpets should be steam cleaned and curtains should be changed following outbreaks. Hypochlorite 1000 ppm is recommended for disinfecting hard surfaces. Further research of environmental contamination and decontamination activities is required.

The dynamics of norovirus outbreak epidemics: recent insights

Noroviruses are a major cause of gastroenteritis outbreaks worldwide. Norovirus outbreaks frequently occur as epidemics which appear to be related to both genetic and environmental factors. This review considers recent progress in understanding these factors. The norovirus genome undergoes continuous change and this appears to be important in the persistence of the virus in the community. Studies on the common GII.4 genotype have shown that some norovirus outbreak epidemics involving this genotype are correlated with specific changes in the genome. In contrast to the growing understanding of the role of genetic factors in norovirus outbreak epidemics, the role of environmental factors is less well understood. Topics reviewed here include long term excretion of norovirus in some individuals, long term survivability of norovirus in the environment, the role of meteorological factors in the control of norovirus outbreaks and the possible zoonotic transmission of the virus.

Long-term features of norovirus gastroenteritis in the elderly

Noroviruses are important pathogens in both sporadic cases and outbreaks of gastroenteritis in humans. Noroviruses can affect individuals of all ages in a variety of settings, but are a particularly important cause of gastroenteritis in aged-care facilities. The relationship between clinical symptoms and norovirus excretion and the possible role of asymptomatic carriage of norovirus in the elderly are poorly understood. This study examined symptoms and norovirus excretion in elderly individuals associated with a norovirus outbreak in an aged-care facility. Ten individuals aged 79-94 years were recruited for the study. Nine were symptomatic and one was an asymptomatic contact who subsequently developed gastroenteritis. The 10 participants were interviewed regarding their clinical symptoms between two and six times over a three-week study period. One or more sequential faecal samples were collected from all participants over the same period and tested by reverse transcription-polymerase chain reaction for the presence of norovirus. Norovirus was detected in faecal samples from all 10 study participants and was commonly detected in formed stools. In the nine symptomatic participants, acute symptoms such as diarrhoea and vomiting had largely resolved by the third or fourth day of illness, but non-specific symptoms such as headache, thirst and vertigo could persist for as long as 19 days. Both acute and non-specific symptoms appeared to resolve and recur in some participants. The median excretion time for norovirus was 8.6 days (range 2-15 days) in symptomatic participants (N=5). There was no general relationship between the duration of norovirus excretion and the duration of either acute or non-specific symptoms. A faecal sample collected from the asymptomatic contact the day before gastroenteritis symptoms began was positive for norovirus, demonstrating prodromal excretion of norovirus. The results of this study indicate that infection control guidelines should consider both long-term excretion and prodromal excretion of norovirus, and the possibility that formed stools can contain norovirus. Furthermore, the care of elderly individuals recovering from a norovirus infection should take long-term non-specific clinical symptoms into account.

Rotavirus detection and characterisation in outbreaks of gastroenteritis in aged-care facilities

BACKGROUND

Although rotavirus is a major cause of gastroenteritis in children, its role in adult gastroenteritis and the sensitivity of different methods for its detection in specimens collected from adults are less well understood.

OBJECTIVES

(1) To examine the frequency and seasonality of rotavirus-associated gastroenteritis outbreaks in aged-care facilities in Victoria, Australia. (2) To determine rotavirus type in these outbreaks. (3) To determine whether other enteropathogenic agents are present in specimens from these outbreaks. (4) To examine the sensitivity of different methods (electron microscopy (EM), reverse transcription-polymerase chain reaction (RT-PCR), enzyme immunoassay (EIA) and latex agglutination (LA)) for the detection of rotavirus in specimens from adults.

STUDY DESIGN

Specimens from gastroenteritis outbreaks in aged-care facilities forwarded to this laboratory for the years 1997-2000 were tested for enteropathogenic agents by various methods. Epidemiological, clinical and seasonal data from the rotavirus-positive outbreaks were analysed.

RESULTS

Rotavirus was detected by EM in 18 out of 29 individuals associated with seven out of 53 (13%) gastroenteritis outbreaks in aged-care facilities; norovirus was detected in 22 outbreaks (42%) and astrovirus in one outbreak (2%). No mixed viral infection was found in any outbreak. All rotaviruses were typed as Group A by RT-PCR. The rotaviruses in the seven outbreaks were G-typed as follows: G2 (three outbreaks), G4 (two outbreaks), G1 (one outbreak) and G9 (one outbreak). The rotavirus-associated outbreaks were concentrated in mid-winter to mid-spring. The relative sensitivities of the Group A rotavirus detection methods (for the 29 specimens tested) were EM (18), first-round RT-PCR (11), second-round PCR (19), EIA-visual (19), EIA-photometric (19) and LA (13).

CONCLUSIONS

In Victoria, Australia, outbreaks of gastroenteritis associated with rotavirus are quite common in aged-care facilities. They involve Group A rotavirus and have a winter/spring seasonality. G-types G1, G2, G4 and G9 were all detected. EIA, second-round PCR and EM proved sensitive methods for rotavirus detection whereas first-round RT-PCR and LA did not.

Incidence and characteristics of endemic Norwalk-like virus-associated gastroenteritis

Endemic gastroenteritis associated with the Norwalk-like viruses (NLVs) is little understood. This study tested for NLV in gastroenteritis cases in 257 households in Melbourne, Australia, for the period September 1997 to February 1999 by a reverse transcription hemi-nested polymerase chain reaction. Positive samples were studied by nucleotide sequencing and phylogenetic analysis. NLV was detected in 73 (11.4%) of 638 faecal specimens tested. Twelve (1.9%) were NLV genogroup 1 (G1) and 61 (9.6%) NLV genogroup 2 (G2). Gastroenteritis symptoms associated with NLV G2/no other pathogens were significantly more severe than where no NLV was detected. NLV G1 and NLV G2 were detected in adults and children, males and females. NLV G2 incidence showed a marked seasonal periodicity with significant peaks in the Australian late spring/early summer periods. NLV G1 seasonality was significantly different from that of NLV G2. Seven major NLV clusters were identified by phylogenetic analysis.

Simultaneous isolation of verotoxin-producing strains of Escherichia coli O128:H2 and viruses in gastroenteritis outbreaks

Three outbreaks of gastroenteritis from which the Verotoxin producing Escherichia coli serotype O128:H2 was isolated are reported. In addition Norwalk-like viruses were detected in patients from two of the outbreaks and astrovirus in the third outbreak. While it cannot be specifically determined which of these agents played the major role in these outbreaks, the findings suggest that the viral agents need to be considered in investigations of gastroenteritis outbreaks, regardless of whether bacterial enteropathogens have also been isolated. This study points to a strong need to investigate gastroenteritis outbreaks for both bacterial and viral agents and to review in detail the asymptomatic carriage rate of Verotoxin-producing bacteria and gastroenteritis-associated viral agents; these areas of public health significance have been largely neglected.

Foodborne viral illness--status in Australia

Norwalk-like virus contamination of oysters and orange juice, and hepatitis A virus contamination of oysters have been responsible for large outbreaks of foodborne viral disease in Australia. Rotavirus, adenovirus, astrovirus, parvovirus and other enteroviruses also contribute to the incidence of gastroenteritis in this country but the role of foods and waters in transmitting these viruses is unclear. Protocols for the investigation, surveillance and reporting of foodborne viral illness require further development to enable a more accurate description of the problem. Few laboratories have the capability to analyse foods for viruses and specific training in this technology is needed. Management of food safety in Australia largely relies on the implementation of HACCP principles, but these need to be adapted to address the specific risks from viruses.

Inactivation of feline calicivirus, a Norwalk virus surrogate

Norwalk and Norwalk virus-like particles (NVLPs) [also known as small round structured viruses (SRSVs)] are members of the family Caliciviridae and are important causes of gastroenteritis in humans. Little is known about their survival in the environment or the disinfection procedures necessary to remove them from contaminated settings. As NVLPs cannot be grown in tissue culture, survival studies require the use of a closely related cultivable virus. This study assesses the survival of the surrogate feline calicivirus (FCV) after exposure to commercially available disinfectants and a range of environmental conditions. Disinfectants tested included glutaraldehyde, iodine, hypochlorite, a quaternary ammonium-based product, an anionic detergent and ethanol. Complete inactivation of FCV required exposure to 1000 ppm freshly reconstituted granular hypochlorite, or 5000 ppm pre-reconstituted hypochlorite solution. Glutaraldehyde and the iodine-based product effectively inactivated FCV whereas the quaternary ammonium product, detergent and ethanol failed to completely inactivate the virus. The stability of FCV in suspension and in a dried state was assessed after exposure to 4 degrees C, room temperature (20 degrees C) and 37 degrees C. With increasing temperature, the stability of FCV was found to diminish both in suspension and in the dried state. FCV in the dried state did not survive for one day at 37 degrees C. This study provides a basis for establishing guidelines for disinfection protocols to decrease the spread of NVLPs in a community setting.

Molecular characterization of Camberwell virus and sequence variation in ORF3 of small round-structured (Norwalk-like) viruses

Five small round-structured viruses (SRSVs) associated with gastroenteritis in Victoria, Australia, from January to November 1994 were examined by sequencing cDNA prepared from faecal samples using RT-PCR. The sequence of the 3' half (3.8 kb) of the genome of one of these viruses, Camberwell, was determined. Camberwell virus was related most closely to Bristol and Lordsdale viruses, and belonged to the genetic group of SRSVs containing Bristol, Lordsdale, Toronto, OTH-25, Mexico, and Hawaii viruses. The amino acid identities between Camberwell and Bristol viruses for proteins encoded by ORF1 (partial), ORF2, and ORF3 were 99%, 98%, and 90%, respectively. A highly variable region in ORF3 corresponding to amino acid residues 123 to 169 (Bristol and Camberwell numbering) were identified. Short segments of ORF1 (polymerase region) and the highly variable ORF3 region was analysed for the other four viruses. The results obtained indicated the potential usefulness of the variable region in distinguishing between closely related viruses.

Coronavirus-like particles in adults in Melbourne, Australia

Coronavirus-like particle(s) (CVLP) are faecal-derived pleomorphic membrane bound virus-like particles characterised by a fringe of club-shaped spikes that measure about 27 nm in length. The association of CVLP with a variety of social, clinical, and epidemiological factors was examined after a 69 month survey of faeces received for routine testing at an infectious diseases hospital. CVLP was found most commonly in three groups: first, intellectually retarded individuals who were usually inmates of institutions; second, recent overseas travellers who were either Indochinese refugees/immigrants or were overseas travellers who had usually visited developing communities for lengthy periods; and, third, male homosexuals who had a history of multiple sexual contacts and/or venereal disease. It was concluded that the excretion of CVLP had a strong association with unhygienic living or working conditions irrespective of any clinical symptoms the individual might show.

Role of infected food handler in hotel outbreak of Norwalk-like viral gastroenteritis: implications for control

Investigation of an outbreak of viral (Norwalk-like) gastroenteritis amongst staff (40 cases), resident guests (over 70 cases), and persons attending functions (54 cases) at one hotel over 8 days suggested that the main vehicle of infection was cold foods prepared by a food handler during and after a mild gastrointestinal illness. He was excreting Norwalk-like virus particles 48 hours after the illness. In addition, ill kitchen staff vomited in the kitchen area and may have contaminated surfaces and stored foods. It is recommended that food handlers should be regarded as potentially infectious until at least 48 hours after clinical recovery from viral gastroenteritis. Stored foods that may have been contaminated should be immediately discarded and areas of the work place which may have been affected should be identified and decontaminated.

Virus and virus-like particles in the faeces of cats with and without diarrhoea

Negative staining electron microscopy was used to identify viruses in 166 normal and 62 diarrhoeal faecal samples from 208 cats admitted to an animal shelter during a 16-month period (March 1984 to June 1985). On the basis of size and shape 7 distinct viral types were detected: 24 nm parvovirus-like particles, 30 nm astrovirus, 30 nm picornavirus-like particles, reovirus, rotavirus, coronavirus and a 75 nm "togavirus-like" particle. The incidence of these particles in the 208 cats was 11%, 7%, 6%, 0.4%, 5%, 1% and 1% respectively. Virus isolation studies using 40 of the faecal samples succeeded in isolating reovirus 1 in 2 cases. Immune electron microscope studies demonstrated the presence of antibody in a human serum to cat astrovirus, but failed to clarify the identity of the parvovirus-like particles and picornavirus-like particles, other than showing that some of the parvovirus-like particles were not related to feline panleukopenia virus. It was found that parvovirus-like particles, astrovirus, picornavirus-like particles, reovirus and rotavirus could be excreted by cats with normal faeces as well as cats with diarrhoeal faeces. Parvovirus-like particles, astrovirus, picornavirus-like particles and rotavirus could be excreted in high concentration in normal faeces. There was no simple relationship between age and diarrhoea in the population of cats studied. Age was not a critical factor in the excretion of parvovirus-like particles, astrovirus, picornavirus-like particles and rotavirus. The incidence of diarrhoea was not clearly associated with the seasons.