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Published Date: 2002-12-18 23:50:00
Subject: PRO/EDR> Viral gastroenteritis update 2002 - (01)
Archive Number: 20021218.6088

VIRAL GASTROENTERITIS UPDATE 2002 - (01)
****************************************
A ProMED-mail post
<http://www.promedmail.org>
ProMED-mail is a program of the
International Society for Infectious Diseases
<http://www.isid.org>
[In view of the increasing volume and diverse origin of reports of
outbreaks of viral gastroenteritis, all such reports will be consolidated
into an edited mid-weekly update. In the case of outbreaks attributable to
caliciviruses, the commonly used designation "Norwalk-like viruses" will be
replaced by the ICTV-approved genus name _Norovirus_. The genus _Norovirus_
is one of 4 genera comprising the family _Caliciviridae_, and the type
species of the genus is _Norwalk virus_. - Mod.CP]
In these updates:
[1] Hospitals - Finland
[2] Schools & health-care facilities - USA (Alaska)
(3) City-wide outbreaks - Canada (Calgary)
[4] & [5] Cruise ship - USA (New Orleans)
******
[1]
Date: Thu 12 Dec 2002
From: ProMED-mail <promed@promedmail.org>
Source: Helsingin Sanomat, Thu 11 Dec 2002 [edited]
<http://www.helsinki-hs.net/news.asp?id=20021211IE7>

Finland: Diarrhea and Vomiting Illness Affects Hospitals Across the Country
--------------------------------------------------
A severe diarrhoea and vomiting epidemic is [affecting] both patients and
staff in hospitals and nursing homes in different locations in Finland.
Earlier in the autumn [viral gastroenteritis] troubled a central hospital
in Lappeenranta in Southeastern Finland, and now it has reached epidemic
proportions at least in Joensuu and Jyvskyl in East and Central Finland.
[Viral gastroenteritis] has also affected people in Vaasa, Kuopio, and
Helsinki. At the emergency room of the Peijas hospital in Vantaa, a large
proportion of the patients are seeking help because of [gastroeneteritis].
They complain about symptoms such as severe abdominal pain, diarrhoea, and
sudden vomiting. Because of the illness, there is some shortage of staff as
well. At the Malmi hospital in Helsinki, [gastroeneteritis] patients keep
the public health nurse busy with requests for medical certificates to give
to their employers. The severe illness can be dangerous to children, the
elderly, and patients with poor general health.
According to paediatrician Kristiina Aalto, the Children and Youth Hospital
of Helsinki has taken in a few children because of [gastroeneteritis] and a
risk of dehydration. Aalto says the vomiting is possibly caused by a
rotavirus. "For children we have recommended Gefilus capsules and Osmosal
drink for diarrhoea. If a child refuses to drink at home, a visit to a
doctor is advisable. The younger the child, the greater the risk of
dehydration", Kristiina Aalto explains.
In the province of Northern Karelia in Eastern Finland the seriousness of
the situation has caused the health authorities to give out an epidemic
warning to all the hospitals and health centres in the area. The doctor of
infectious diseases Risto Tillikainen says there are hundreds of
[gastroenteritis] patients in the city of Joensuu. According to Tillikainen
symptoms [suggest] calicivirus infection. At the University Central
Hospital in Kuopio, at least one ward has been hit by the disease, and 20
or so patients and staff members have been infected. Senior physician
Sirkka Keikkala of the Jyvskyl city health centre says the diarrhoea
epidemic is spreading in Jyvskyl as well. Last week around 20 patients and
a dozen health centre staff members complained about stomach problems. 20
patients of the nearby Syntsalo nursing home have also caught the disease.
Senior physician Petri Ruutu from the Finnish Public Health Institute says
the overall picture of the epidemic has not yet been mapped out. "Usually
this type of diarrhoea spreading through institutions have been caused by
caliciviruses. Microbiological testing, however, has so far only been
carried out on a very small sample of the less severe forms of the illness."
--
ProMED-mail
<promed@promedmail.org>
[Gastroenteritis in young children is usually a consequence of rotavirus
infection, whereas caliciviruses are associated with gastroenteritis in
older children, adults, and the elderly. However, where patients of all
ages are involved, laboratory confirmation of diagnosis is desirable. - Mod.CP]
******
[2]
Date: Fri 13 Dec 2002
From: Liz Brown <Liz_Brown@envircon.state.ak.us>
Source: State of Alaska, Health and Social Services, Epidemiology Section,
Thu 12 Dec 2002 [edited]
<http://www.epi.hss.state.ak.us/bulletins/docs/b2002_30.pdf>

USA (Alaska): Outbreak of Gastroenteritis in Ketchikan - Interim Report
-----------------------------------------------------------------------
On 9 Dec 2002, the Section of Epidemiology was informed of numerous cases
of gastroenteritis in Ketchikan. Reports involved sudden onset of nausea,
vomiting, and diarrhea among persons affiliated with one nursing home, 2
elementary schools, and 2 day-care facilities.
As of Thu 12 Dec 2002, 34 persons were interviewed, 13 were male. The ages
ranged from 10 months to 93 years; median age, 28 years. The earliest case
occurred on 17 Nov 2002 with subsequent cases occurring in December. The
mean duration of illness was 2.5 days. Symptoms included nausea (76
percent), vomiting (70 percent), diarrhea (91 percent), hematochezia (9
percent), abdominal cramping (61 percent), feverishness (47 percent),
chills (47 percent), headache (41 percent), body ache (47 percent), and
fatigue (66 percent). Most (55 percent) had seen a health-care provider, 6
percent were hospitalized overnight. Household contacts that were also ill
with similar symptoms were identified in 74 percent of persons interviewed.
Elevated absentee rates over the previous week were reported from 2
elementary schools totaling approximately 60 students. Bulk stool specimens
were collected for [norovirus], bacterial, and parasitic testing.
Discussion: An outbreak of gastroenteritis characterized by sudden onset of
nausea, vomiting, and diarrhea is currently ongoing in Ketchikan, with
demonstration of multiple foci within the community and likely
person-to-person spread within households. The most likely pathogen
responsible for the outbreak is a [norovirus]. Investigators are attempting
to determine the original source of the outbreak and confirm the diagnosis.
Laboratory results are pending.
National estimates are that 65 percent of all non-bacterial gastroenteritis
in the United States are due to noroviruses. Noroviruses are small RNA
viruses classified [in the family _Caliciviridae_]. Gastroenteritis due to
noroviruses has an average incubation period of 24 to 48 hours (range 18 to
72 hours), and symptoms can last 12 to 72 hours. Symptoms include acute
onset of abdominal cramps, nausea, vomiting, and diarrhea. Constitutional
symptoms of headache, fever (101 F to 102 F), chills, and myalgia are
frequently reported. Diarrhea can occur 4 to 8 times within 24 hours, and
stools are described as loose to watery, without blood, mucus, or fecal
leukocytes. Severe dehydration can occur. Long-term sequelae of norovirus
infection have not been reported. Noroviruses are acquired through
ingestion of viral particles. The infectious dose for noroviruses is <100
viral particles, and the virus is effectively transmitted by contact with
contaminated objects such as door knobs. Noroviruses are able to survive in
chlorinated water and temperatures from 32 F to 145 F. Viral shedding in
stool can persist for up to 2 weeks after resolution of symptoms.
Noroviruses cannot be cultured and are identified by polymerase chain
reaction (PCR) techniques on bulk stool samples or vomitus. Noroviral
disease usually resolves without specific treatment; however, some patients
may require fluid replacement and symptomatic treatment for headache,
myalgia, and nausea. No vaccines exist for norovviruses.
Recommendations:
1. All ill individuals and families in households with ill members should
meticulously and frequently wash their hands. Hand washing is vital to stop
spread to other members of families.
2. All food handlers in Ketchikan should meticulously and frequently wash
their hands after toileting and prior to preparing food. Food handlers who
are acutely ill with vomiting or diarrhea should not work until the
symptoms have ceased.
3. In schools and other institutions where illness has been observed, hard
surfaces that are touched by humans, including foot traffic areas (such as
counter tops, bathroom surfaces, doorknobs, handrails, telephones, and
floors should be aggressively cleaned and then disinfected using chlorine
bleach at a concentration of 1000 ppm (1/2 cup/gallon). Chlorine bleach at
a concentration of 5000 ppm (2-1/2 cups/gallon) should be used for areas
suspected of direct noroviral contamination, e.g., where vomitus has
occurred. Housekeeping personnel should wear gloves when cleaning up vomitus.
4. Ketchikan residents who are ill with vomiting or diarrhea should call
the Ketchikan Health Center to report their illness.
5. Individuals with mild illness should drink plenty of fluids to maintain
their hydration status. Individuals who are severely ill should call their
health-care provider.
--
Liz Brown
<Liz_Brown@envircon.state.ak.us>
******
[3]
Date: Sat 14 Dec 2002
From: ProMED-mail <promed@promedmail.org>
Source: Canada.com, Calgary Herald report, Sat 14 Dec 2002 [edited]
<http://www.canada.com/calgary/news/story.asp?id={71726D73-4AF8-45D5-8F90-D6
D55616B828}>

Calgary: Norovirus Victims Approach 1000
------------------------------------------------
Nearly 1000 Calgarians have fallen ill to [norovirus] infection since
October 2002, prompting the Calgary Health Region to issue a warning on Fri
13 Dec 2002 to those who plan on visiting friends and family in care
facilities over the holidays. Since October 2002, 30 locations in the city
have had staff, students, and patients affected by the gastrointestinal
virus, up drastically from the same period last year, when only one
outbreak affecting seven people was reported.
The first half of this month alone has seen 18 outbreaks of the virus that
[affects] people with violent [gastrointestinal] symptoms for 48 hours.
After a norovirus outbreak 2 weeks ago, 2 geriatric wards at the Rockyview
Hospital are still not admitting patients. At the same time, Varsity Acres
Elementary School in the city's northwest had to be scrubbed from top to
bottom when some 100 students came down with either norovirus infection or
chicken pox. The Bethany Care Centre also enforced precautionary measures
when 5 people came down with symptoms of norovirus infection last week.
Mary LeBlanc, the Carewest coordinator of infection prevention and control,
said signs have been put up at several senior living centres discouraging
visitors during the holidays. Cleaning and disinfecting practices have also
been stepped up in an effort to keep at bay the virus that is most
prevalent in winter.
17 of the 30 outbreak locations -- an infected person is referred to as a
case, a collection of cases is an outbreak -- are still fighting off the
[virus]. The other 13 norovirus outbreaks have run their course. 2 years
ago, between October and December, 15 outbreaks were reported affecting 925
people.
In order to curb the spread of the virus, health care officials are urging
anyone visiting hospitals or seniors' homes to not bring gifts that will be
handled by more than one person, like holiday food items, and to wash their
hands before and after the visit. As well, people should delay their visit
if they aren't feeling well and wait at least 48 hours if they are
experiencing symptoms of vomiting or diarrhea.
[Byline: Maria Canton and Sorcha McGinnis]
******
[4]
Date: Sun 15 Dec 2002
From: ProMED-mail <promed@promedmail.org>
Source: Associated Press Online, Sun 15 Dec 2002 [edited]

200 Reported Ill On Cruise Ship Based in New Orleans
--------------------------------------------------
More than 200 guests on the cruise ship Carnival Conquest reported symptoms
of a gastrointestinal illness on a voyage that ended Sun 15 Dec 2002,
Carnival Cruise Lines said. The company said it was treating the illness as
[norovirus related], the same type of illness that has affected hundreds of
passengers on other cruise ships in recent months. Carnival said it was
working with the federal Centers for Disease Control and Prevention to
determine the cause.
The Conquest, which had 3160 passengers, left New Orleans on 8 Dec 2002.
Its next 7-day cruise, to the western Caribbean, was expected to depart
Sunday evening. Company officials said they had informed passengers of the
outbreak and were offering refunds to any who did not want to sail.
******
[5]
Date: Mon 16 Dec 2002
From: H. Larry Penning, M.D. <hlpenning@yahoo.com>
Source: The Times-Picayune, Metro News, nola.com, Mon 16 Dec 2202 [edited]
<http://www.nola.com/news/t-p/metro/index.ssf?/newsstory/cruiser16.html>

New Orleans: Cruise Ship Sailing Delayed for Disinfection
--------------------------------------------------
Carnival Cruise Line's Conquest, New Orleans' newest and tallest cruise
ship tenant, reported almost 230 cases of gastrointestinal illnesses during
its most recent voyage, triggering a sanitation effort that delayed the
departure of its next Caribbean cruise by several hours. More than 200 of
the 3160 guests and about 25 of the 1160 crew members were stricken with
nausea, vomiting, and diarrhea during the 7 -day cruise to the western
Caribbean that ended early Sunday at the Port of New Orleans, said Steve
Williams, Carnival's director of medical operations.
While test results are pending, ship and federal health officials are
treating it as an outbreak of a norovirus infection, a highly contagious
illness that can be spread by contact with infected people or surfaces,
Williams said. "This is not a case of the ship being sick," he said of the
Conquest, a $500 million vessel that began its inaugural week long cruise
on 1 Dec 2002. Since October, more than 1500 people have had similar
stomach ailments on several other cruise liners owned by Carnival, Holland
America Line and Disney Cruise Line. The illnesses' spread is attributed to
infected people in confined spaces. "Cruise ships are a microcosm of
society," Williams said.
Carnival officials think the source of the Conquest's woes is a guest who
said he had symptoms about 2 days before the ship left New Orleans on 8 Dec
2002; the ship's crew did not begin to get ill until midway in the voyage.
Williams said he was notified by the ship's medical staff Tuesday of the
rising number of illnesses. Infected passengers and crew were quarantined
in their cabins, he said, a response recommended by the Centers for Disease
Control and Prevention. Other measures included using the ship's staff to
serve food on buffet lines rather than letting passengers serve themselves.
The infected people were spread throughout the 952-foot ship, which has 13
guest decks and 1487 cabins. Crew who became ill included senior staff
members and others who have contact with guests. The ill passengers left
the Conquest early on Sunday, a Harbor Police officer said.
About 70 workers were using chemicals to clean rooms and public surfaces,
including casino chips, before the ship's next 7-day cruise that was
scheduled to leave on Sunday evening, delaying the departure by several
hours. CDC and U.S. Health Service inspectors were on board, Williams said.
[Byline: Paul Purpura]
--
H. Larry Penning, M.D.
<hlpenning@yahoo.com>

See Also