viral gastro

Agents of Viral Gastroenteritis

Erik Reisdorf CLS M (NCA)Advanced MicrobiologistCommunicable Disease DivisionWisconsin State Laboratory of HygieneFebruary 25, 2004

ACUTE INFECTIOUS GASTROENTERITISPUBLIC HEALTH IMPACT United StatesSecond most common clinical entityGreatest clinical impact on children < 5500,000 physician visits55,000 children hospitalized per year>500 deaths per year$1 billion in total costsWorldwide Estimated 3-5 billion cases occur annually5-10 million deaths annually primarily in developing countries

Incidence of Foodborne Illness

Incidence of cases of infection with pathogens under surveillance by CDC (FoodNET)

United States 2001

Pathogen (bacterial/parasitic)

Overall Incidence (per 100,000)

Salmonella

15.1

Campylobacter

13.8

Shigella

6.4

E. coli 0157

1.6

Cryptosporidium

1.5

HUS

0.9

Yersinia

0.4

Listeria

0.3

Vibrio

0.2

Cyclospora

0.1

Etiologic Agents Associated With FBOs 1991-2000 (n=231)

FOODBORNE & WATERBORNE GASTROENTERITISAn Emerging Public Health Problem

FOODBORNE & WATERBORNE GASTROENTERITISThe Viral AgentsNorovirus (norwalk-like)Rotavirus Adenovirus 40/41 AstrovirusOther?

FOODBORNE & WATERBORNE GASTROENTERITIS CLUES AS TO ETIOLOGYClinical FeaturesIncubation PeriodDuration of IllnessSeasonalityGeographic Location

FOODBORNE & WATERBORNE GASTROENTERITISClinical Clues

FOODBORNE & WATERBORNE GASTROENTERITIS CLINICAL CLUES (V)Nausea, Vomiting, and Diarrhea Incubation:24 - 48 hoursDuration:24 - 48 hours

Etiology:norovirus (previously known as norwalk-like virus)

FOODBORNE & WATERBORNE GASTROENTERITIS NOROVIRUS

FOODBORNE & WATERBORNE GASTROENTERITISHelpful Hints for the Clueless ClinicianBloody (with mucus) diarrheaFeverChronicityAgeSeasonalityTwo or more people involvedRetrospective chart reviewWhen in doubt, contact your LPHA

VIRAL GASTROENTERITISMajor Etiologic AgentsNorovirus Largest cause of outbreaks of nonbacterial gastroenteritis (>90%)RotavirusesAdenovirus Types 40 and 41Astroviruses

OTHER VIRUSES IMPLICATED IN GASTROENTERITISSRSVscoronavirusPestivirusPicobirnavirusTorovirus Parvovirus Etiological role and public health significance unclear!

VIRAL GASTROENTERITISEnteroviruses Another Major Player?

NOT!

VIRAL GASTROENTERITISRotavirusesFamily ReoviridaedsRNA (11 segments), non-enveloped; 70nm5 groups, A - E:Group A (subtypes 1 - 4) - 1 human pathogensGroup B - extensive outbreaks in ChinaGroup C - occasional illness worldwideGroups D and E - animal pathogens

VIRAL GASTROENTERITISRotavirus Clinical IllnessIncubation period: 1 - 3 daysDuration: 3 - 8 daysCharacteristic clinical triad:fevervomitingdiarrheaFrequent coryza and coughDehydration is leading complication

VIRAL GASTROENTERITISRotavirus EpidemiologyMax. incidence of illness: 6 - 24 monthsReinfection common throughout lifeInfections at < 6 months and > 5 years of age often asymptomatic or mildSeasonality: Marked; winter-spring peak in WITransmission:person-to-person; fecal - oral; respiratory?

ROTAVIRUS IN WISCONSIN

Chart1

1195.2631578947

42913.7931034483

1234.347826087

0300

0320

21910.5263157895

1175.8823529412

21811.1111111111

21910.5263157895

1520

32512

1185.5555555556

2229.0909090909

2355.7142857143

43810.5263157895

53514.2857142857

3339.0909090909

53613.8888888889

114425

3446.8181818182

125024

95715.7894736842

85016

155626.7857142857

206132.7868852459

338339.7590361446

268231.7073170732

398844.3181818182

326946.3768115942

4010040

4610444.2307692308

479648.9583333333

489948.4848484848

6112449.1935483871

398744.8275862069

479251.0869565217

388544.7058823529

259626.0416666667

165529.0909090909

73321.2121212121

166126.2295081967

3407.5

3456.6666666667

33010

Data Collated by WSLH

Pos. Rota

Total Rota

% Pos. Rota

Week Ending

No. Pos/Tested

Percent Pos.

ro9596

BellinSt. VincentsGundersen LutheranSt. MarysWSLHMarshfieldMilwaukee HlthUnited RegionalChildrensMedical ScienceTotal

PosTotalPosTotalPosTotalPosTotalPosTotalPosTotalPosTotalPosTotalPosTotalPosTotalPos

11/25/9500

12/2/95110

12/9/95110

12/16/9500

12/23/9500

12/30/95110

1/6/9600

1/13/9600

1/20/96220

1/27/9611350

2/3/9600

2/10/96330

2/17/962350

2/24/96417354240

3/2/96433363220

3/9/9613117130

3/16/96422254190

3/23/9668251174430

3/30/96487723113378

4/6/9634833102330

4/13/96534312270

4/20/96342371200

4/27/964311180

5/4/962431100

5/11/963140

5/18/9631260

5/25/9611130

6/1/96220

6/8/9600

6/15/96110

6/22/9600200020006028

6/29/9600100130016039

2584105602602601055250001120030525

&CNumber of Patients Tested and Positive for Rotavirus in Wisconsin

ro9596

0000000000

0000000000

0000000000

0000000000

0000000000

0000000000

0000000000

0000000000

0000000000

0000000000

0000000000

0000000000

0000000000

0000000000

0000000000

0000000000

0000000000

0000000000

0000000000

0000000000

0000000000

0000000000

0000000000

0000000000

0000000000

0000000000

0000000000

0000000000

0000000000

0000000000

0000000000

0000000000


Bellin Pos

Bellin Total

St. Vincents Pos

St. Vincents Total

Gundersen Lutheran Pos

Gundersen Lutheran Total

St. Marys Pos

St. Marys Total

WSLH Pos

WSLH Total

Marshfield Pos

Marshfield Total

Milwaukee Hlth Pos

Milwaukee Hlth Total

United Regional Pos

United Regional Total

Childrens Pos

Childrens Total

Medical Science Pos

ro9697

BellinSt. VincentsGundersen LutheranSt. MarysWSLHMarshfieldMilwaukee HlthUnited RegionalChildrensMedical ScienceTotalTotalPercent

PosTotalPosTotalPosTotalPosTotalPosTotalPosTotalPosTotalPosTotalPosTotalPosTotalPos. RotaTotal Rota% Pos. Rota

7/6/9616000108031185.56

7/13/96020100150011021811.11

7/20/96110005010001051137.69

7/27/9601000002040017001147.14

8/3/96000000020102030006000140.00

8/10/960911010003020002001185.56

8/17/960101010006030006000180.00

8/24/960401020003060101030210.00

8/31/960201010105120006021205.00

9/7/960302110101010305021195.26

9/14/961202030039060200030242913.79

9/21/96020100001407040005001234.35

9/28/960800020102020300011010300.00

10/5/960702030102010200012020320.00

10/12/9605000011031301050121910.53

10/19/961400000405000004001175.88

10/26/9611050300150300010021811.11

11/2/961213020000060300020121910.53

11/9/960200110000020000001520.00

11/16/963701000202040200060132512.00

11/23/960306000001010401121185.56

11/30/96020200010202030029012229.09

12/7/960206010101010501216012355.71

12/14/9613030202010405023140243810.53

12/21/9600000101010502015220253514.29

12/28/960211030001020402218003339.09

1/4/9704020200000105025190153613.89

1/11/97361412001113040141904114425.00

1/18/970501030105061300217033446.82

1/25/97010212011213170282901125024.00

2/1/9702130503010714047240495715.79

2/8/97150203001207111004161485016.00

2/15/971337022313210170141911155626.79

2/22/9701381115021331200102613206132.79

3/1/97137130245234173600113212338339.76

3/8/9727816250035082120292601268231.71

3/15/971856032301374800245101398844.32

3/22/974658222302280401163411326946.38

3/29/973861211226841507021640254010040.00

4/5/9751461222122341025112252134610444.23

4/12/97610493411454112511214515479648.96

4/19/97698127712239192711113514489948.48

4/26/977101115577141861526121842356112449.19

5/3/9757694503376183912112601398744.83

5/10/977108123557241021260162046479251.09

5/17/97474823442511201100082523388544.71

5/24/97510292627136200150062511259626.04

5/31/9725292501491200524165529.09

6/7/9737030301132400001120073321.21

6/14/9731138230113510030321900166126.23

6/21/9714240000040100300014013407.50

6/28/972500130007050904010023456.67

7/5/970700220101050700061133010.00

7/12/97070104000019050005021333.03

7/19/970201000309090001000250.00

7/26/970105000103040008020240.00

8/2/97020801014040405050430.00

8/9/9703000105090008020280.00

00

8025898252471243486391538839634269542248911211006942591

31.0138.8937.9039.5325.4922.2212.6411.9027.2221.0026.79


&C&P

ro9697

35252352521600352523525201083525235252352523525233525235252118

3525935259020135259352590015352593525900103525935259218

3526635266352663526611000501352663526600105113

35273352730100000204352733527300700114

0000000201020300600014

093528735287110100030200200118

013529435294010100060300600018

043530135301010200030601103021

023530835308010101051200602120

030211010101353153531503502119

1202030039060200302429

0201000014070400500123

08000201020203001101030

07020301020102001202032

053535035350000011031301501219

143535735357000004050000400117

110503353643536400150300100218

1213020000060300201219

0200110000020000353780015

3701000202040200601325

030600000101040123539235392118

0202000102020300901222

02060101010105011601235

13030202010405021402438

00000101010502012202535

02110300010204021800333

04020200000105021901536

361412001113040119041144

05010301050613001703344

010212011213170229011250

02130503010714042404957

150203001207111001614850

1337022313210170119111556

0138111502133120026132061

13713024523417360032123383

27816250035082120226012682

185603230137480051013988

465822230228040134113269

386121122684150702402540100

5146122212234102511521346104

61049341145411251145154796

69812771223919271135144899

710111557714186152612423561124

5769450337618391226013987

7108123557241021260120464792

474823442511201100025233885

510292627136200150025112596

&CNumber of Patientse Tested and Positive for Rotavirus in Wisconsin

Bellin Pos

Bellin Total

St. Vincents Pos

St. Vincents Total


Gundersen Lutheran Total

St. Marys Pos

St. Marys Total

WSLH Pos

WSLH Total

Marshfield Pos

Marshfield Total

Milwaukee Hlth Pos

Milwaukee Hlth Total

United Regional Pos

United Regional Total

Childrens Total

Medical Science Pos

Medical Science Total

Total Pos

Total Tested

rota 9697

&C&"Arial,Bold"&14Number of Patients Tested and Positive for Rotavirus&12Week Ending September 6, 1997 - April 25, 1998

rota 9697

1195.2631578947

42913.7931034483

1234.347826087

0300

0320

21910.5263157895

1175.8823529412

21811.1111111111

21910.5263157895

1520

32512

1185.5555555556

2229.0909090909

2355.7142857143

43810.5263157895

53514.2857142857

3339.0909090909

53613.8888888889

114425

3446.8181818182

125024

95715.7894736842

85016

155626.7857142857

206132.7868852459

338339.7590361446

268231.7073170732

398844.3181818182

326946.3768115942

4010040

4610444.2307692308

479648.9583333333

489948.4848484848

6112449.1935483871

398744.8275862069

479251.0869565217

388544.7058823529

259626.0416666667

165529.0909090909

73321.2121212121

166126.2295081967

3407.5

3456.6666666667

33010


Pos. Rota

Total Rota

% Pos. Rota

Week Ending

No. Pos/Tested

Percent Pos.

rocurve

rocurve

35252103525200352523525203525218

3525900352590135259013525918

352663526610003526600013

35273000003527301014

000000000014

0352871000000018

0352940000000018

0353010000000021

0353080000100020

0010003531500019

100030000029

000010000023

000000000030

000000000032

0353500010100019

1353570000000017

1003536401000018

110000000019

001000003537805

300000000025

0000000013539218

000000002022

000000002035

100000003038

000000005035

010000002033

000000005036

311011004044

000000102044

001011108050

010000107057

100010104150

130212104156

0311013010161

1704243011183

282030209082

1502034024088

4522020016169

36126400162100

56212421221104

6431442121196

6871292111199

711571621183124

5640363111087

7835210206492

4424211108285

522216006196

22235581041053558155

300012001033

332015002061

120000000040

201000000045

002000000130

000001000033

0003563000000025

0003563700000024

00035644000356440043

35651356510000000028

0

&C&"Arial,Bold"&14Number of Patients Tested and Positive for Rotavirus in Wisconsin

Bellin Pos

St. Vincents Pos


St. Marys Pos

WSLH Pos

Marshfield Pos

Milwaukee Hlth Pos

United Regional Pos

Childrens Pos

Medical Science Pos

Total Tested

Week Ending

No. Positive

No. Tested

rocurve no tot

rocurve no tot

00100035315000

1000300000

0000100000

0000000000

0000000000

03535000101000

13535700000000

10035364010000

1100000000

00100000353780

3000000000

00000000135392

0000000020

0000000020

1000000030

0000000050

0100000020

0000000050

3110110040

0000001020

0010111080

0100001070

1000101041

1302121041

03110130101

17042430111

2820302090

15020340240

45220200161

36126400162

56212421221

64314421211

68712921111

711571621183

56403631110

78352102064

44242111082

5222160061

&C&"Arial,Bold"&14Number of Patients Tested and Positive for Rotavirus in Wisconsin

Bellin Pos

St. Vincents Pos


St. Marys Pos

WSLH Pos

Marshfield Pos

Milwaukee Hlth Pos

United Regional Pos

Childrens Pos

Medical Science Pos

Week Ending

No. Positive

Rota 9798

Rota 9798

0240

0330

0250

1234.347826087

2248.3333333333

1185.5555555556

0220

0210

1214.7619047619

0200

21513.3333333333

2296.8965517241

1244.1666666667

32015

3417.3170731707

4626.4516129032

0460

4478.5106382979

75313.2075471698

115918.6440677966

95217.3076923077

4527.6923076923

4577.0175438596

74316.2790697674

106116.393442623

105717.5438596491

208025

2610325.2427184466

358541.1764705882

328836.3636363636

388246.3414634146

429345.1612903226

409243.4782608696

256637.8787878788


Rota

Total Rota

% Pos Rota

Week Ending

No. Pos./Tested

Percent Pos.

Number of Patients Tested and Positive for RotavirusWeek Ending September 6, 1997 - April 25, 1998

VIRAL GASTROENTERITISCalicivirusesFamily Caliciviridaegenus norovirusssRNA, non-enveloped; 26 - 34 nm4 genogroups; GI 25% GII 75% GIII+IV animalsMany different genetic clusters (>17)

VIRAL GASTROENTERITISNorovirus Clinical IllnessIncubation: 1-2 daysDuration: 2-3 daysAbrupt onset of nausea and vomiting with prostration and malaiseNausea, vomiting, diarrhea, and headache >50%

VIRAL GASTROENTERITISNorovirus Epidemiology23 million annuallyAll ages affected Occurs year aroundWinter vomiting diseaseExplosive family, institutional, and community-wide outbreaksasymptomatic excretion

VIRAL GASTROENTERITISNorovirus CharacteristicsNon cultivitableVomitus infectiousReservoirHighly transmissible Environmentally stable

Seasonality

Person-to-Person Spread

Wisconsin: winter of 2002-2003

WisconsinNovember 2002 through February 2003 there was a marked increase outbreaks:9 institutional2000: 22001: 4

The National PictureTrend reflected nationally:Washington State:November- December 2002: 10 outbreaks (6 LTCF)New Hampshire:November-December 2002: 29 outbreaks (LTCF)NYC:November-January 2003: 66 outbreaks of AGE (51 LTCF)

Theories???

VIRAL GASTROENTERITISAdenovirusesFamily AdenoviridaedsDNA, non-enveloped; 70 - 75 nm2 enteric serotypes: 40 and 41

VIRAL GASTROENTERITISAdenovirus 40/41 Clinical IllnessIncubation: 7 - 8 daysDuration: 8 - 12 daysDiarrhea predominates

VIRAL GASTROENTERITISAdenovirus 40/41 EpidemiologySecond leading cause of cases (5-20%) and hospitalizations in infants Occurs year around; no seasonal peakPredominates in late fall and winterAsymptomatic or mild illness in older children, adultsTransmission: person-to-person

VIRAL GASTROENTERITISAstrovirusesFamily AstroviridaessRNA, non-enveloped; 28 - 30 nm> 5 serotypes?

VIRAL GASTROENTERITISAstrovirus Clinical IllnessIncubation: 3 - 4 daysDuration: < 5 daysIllness milder than RotavirusDiarrhea and low grade fever predominate

VIRAL GASTROENTERITISAstrovirus EpidemiologyCommunity impact uncertainMost common in < 3 years of age; often asymptomaticMild illness in adultsWinter peak in temperate climatesTransmission: person-to-person; water/food?

GASTROENTERITIS VIRUSESPATHOGENETIC CHARACTERISTICSType of infection: acute, localizedGastrointestinal tract is target organIncubation period: generally short, 1-4daysException is adenovirus type 40 and 41infections (7-8days)Mechanism of transmission: person-to-person via fecal-oral route; food-and water-borne Viruses environmentally stableFrequency of inapparent infections: low (except Astrovirus) for primary infection; increase with re-infection (Rotavirus) Symptomatic re-infections: commonImplies poor long-term immunityProlonged virus shedding: common with adenovirus; can occur with rotavirus Illnesses often more severe in compromised hosts

VIRAL GASTROENTERITISLaboratory Diagnosis

VIRAL GASTROENTERITISGuidelines for Specimen CollectionCollect stool within 48 hours after onsetBulk sample; no preservatives; rectal swabs of little valueRefrigerate at 4C; do not freeze

VIRAL GASTROENTERITISLaboratory Testing AvailableRotavirus: EIA*, LA, EM, RT-PCRAdenovirus 40/41: EIA*Norovirus: RT-PCR*, EMAstrovirus: RT-PCR*, EM

* Method of Choice

VIRAL GASTROENTERITISTreatment

Fluid and electrolyte replacement

VIRAL GASTROENTERITISPreventionHand washing; hygiene; cohorting infantsRotavirus vaccineLive, attenuated, reassortant, oral vaccineDirected against group A, serotypes 1 - 4Universal administration 2, 4 and 6 monthsUSE OF THE VACCINE HAS BEEN SUSPENDED DUE TO CLINICAL COMPLICATIONS!

viral gastro

Documents