noroviruses niv seerpi & mark sears green river district health department
TRANSCRIPT
Introducing the artiste formerly known as NLV
Noroviruses (genus Noroviruses, family Caliciviridae) are a group of related RNA viruses that cause acute gastroenteritis in humans
These viruses were formerly known as “Norwalk-like viruses”
Were also referred to as Caliciviruses, and as Small Round Structured Viruses, or SRSVs
Noroviruses
Named after the original strain which caused an outbreak of gastroenteritis in a school in Norwalk, Ohio, in 1968
Currently, there are atleast five norovirus genogroups (GI, GII, GIII, GIV & GV) which in turn are divided into at least 31 genetic clusters
Clinical Presentation
Incubation period – 24 to 48 hrs, can be as short as 12 hrs
Acute onset vomiting, watery non-bloody diarrhea, abdominal cramps, nausea, low-grade fever
Symptoms usually short-lived, 24-60 hours Complete recovery with no long-term
sequelae
Transmission
Fecal-oral route, either by consumption of fecally contaminated food or water or direct person-to-person spread
Environmental & fomite transmission Aerosolization of vomitus results in droplets
that contaminate surfaces or may enter the oral mucosa
Immunity
Highly contagious Shedding usually begins with onset of
symptoms and may continue for 2 weeks after
Immunity is strain-specific and lasts only a few months
Due to genetic variability of noroviruses, individuals are likely to be repeatedly infected throughout their life-times
Disease Burden
CDC estimates that 23 million cases of acute gastroenteritis that occur annually are due to norovirus infection
At least 50% of all food-borne outbreaks can be attributed to noroviruses
Outbreaks
Contamination of food by a food handler immediately before it’s consumption
Usually associated with consumption of cold foods like salads, sandwiches, and bakery products
Other foods implicated include oysters, and produce like raspberries
Sewage contamination of wells & recreational water have led to community outbreaks
Diagnosis
Use of Reverse Transcriptase Polymerase Chain Reaction
Identification of virus from stool specimens taken 48-72 hours after onset
Older methods include electron microscopy, and detection of four-fold increase of specific antibodies in acute & convalescent phase blood samples
Diagnosis
Sequencing of noroviruses helps by linking cases to each other in Epi investigations
Sequences are entered into CaliciNet – a database used to store the different sequences of noroviruses
Management
Symptomatic therapy to replace fluid loss & correct electrolyte disturbances through oral and IV fluid administration
Noroviruses in congregate settings
Noroviruses can spread rapidly in congregate living conditions
- Nursing Homes- Schools- Cruise ships
In the Green River District
4 outbreaks of Norovirus in nursing homes in the past 4 months
1 outbreak on a steamboat cruise on the Ohio River
What is the Health Departments role in an outbreak? Confirm existence of an outbreak Define case Data collection Coordinate collection of lab specimens & their
submission Institute disease control & prevention measures Active surveillance measures Determine when an outbreak is over Enhanced surveillance post-outbreak Data analysis Communicate findings
It all began….on a Friday afternoon
On Friday October 20, 2006, at 3.00 pm the GRDHD Epidemiologist was contacted by the ICN at Henderson Methodist Hospital
She relayed information that a steamboat with sick passengers was docking at Henderson later that day
The hospital was asked to prepare to treat these patients
Details about the numbers and the nature of illness were not available
Conference Call A few minutes later, Dr Thoroughman called to ask us
to participate in a conference call pertaining to illness on board the Mississippi Queen
The Mississippi Queen had started this cruise on October 18 in Cincinnati, OH, and was scheduled to dock at Louisville, Henderson, Paducah, Cape Girardeau, MO, and conclude in St. Louis, MO on the October 25.
Staff from the Kentucky DPH, Cincinnati DPH, West Virginia DPH, CDC & FDA participated in the call
Conference Call (cont)
A clearer picture of the symptomology was presented; although details about numbers affected were sketchy
It was then decided that Niv Seerpi, Epidemiologist and Mark Sears, Environmental Director would meet the boat at the Henderson riverfront and accompany the boat from Henderson to Paducah, which was their next stop
A six member CDC team was to join us in Paducah
CDC Involvement
Later that evening we were contacted by Anandi Sheth, MD, the CDC officer who was heading the investigation
She faxed the Passenger Questionnaire - the survey instrument that was to be administered to all passengers & crew on board
Mississippi Queen
We boarded the boat at 8:30 pm that evening We spoke with the crew members and made
arrangements for the questionnaires to be handed out
We also made preliminary recommendations regarding infection control & disinfection
We also examined the vessel’s gastrointestinal illness log
And we are on our way….
The boat was to depart for Paducah at noon on the 21st of October
A representative of the US Food & Drug Administration joined us at the Henderson riverfront and accompanied us on the trip from Henderson to Paducah
Passengers On October 20-21, 34 passengers were treated at
Methodist Hospital in Henderson for symptoms of nausea, diarrhea and dehydration
Stool specimens were collected from 8 hospitalized passengers
Three passengers were treated at Owensboro Medical Health System
Other passengers who were not ill but wished to leave the boat were provided lodging at a hotel in Evansville, IN
Measures
Outbreak control measures observed:– Hand sanitizers were strategically placed– All sheets were washed in water >180 degrees F– All blankets were replaced with new, all
bedspreads were removed for dry-cleaning– A private cleaning contractor was brought on
board to wipe down all hard surfaces using phenolic-based cleaner
– Public restrooms were closed– No self-service at the luncheon/dinner buffets
Inspection During the trip from Henderson to Paducah, the
GRDHD and FDA Staff checked the water supply, food handling practices, general sanitation procedures and disease control procedures aboard the boat
In addition, we gathered information from the passengers and crew to try to pinpoint a common source of contamination
We obtained completed surveys from 390 of 512 (76%) passengers and crew onboard
CDC Team arrives…
The investigation was turned over to the CDC Epi Investigation Team and the staff of the Purchase District Health Department at the Paducah Riverfront
As some of the ill passengers were taken to an area
hospital as well as local hotels, the Purchase District Health Department checked for secondary cases and educated hotel staff on disease control precautions
Similar practices were instituted at the hotels in Evansville, IN
Cruise discontinued This cruise was cancelled at its Cape Girardeau, MO
stop and all remaining passengers were transported by bus to the final destination of St. Louis, MO due to continued illness onboard
A total of 156 passengers (42%) and 16 crew (11%) reported illness on this cruise
CDC Labs confirmed the presence of GII Noroviruses
in stool specimens that were collected at different stops along the way – Henderson, Paducah & Cape Girardeau
Investigation continues
Despite a thorough cleaning and sanitization supervised by the CDC and the FDA, another outbreak occurred on the next cruise, and this cruise was discontinued after only 3 days
The CDC and the FDA continue to investigate these outbreaks of noroviruses aboard the Mississippi Queen