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Published Date: 2004-12-22 23:50:00
Subject: PRO/EDR> Viral gastroenteritis update 2004 (36)
Archive Number: 20041222.3379

VIRAL GASTROENTERITIS UPDATE 2004 (36)
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In this update:
[1] Norovirus, veterans home - USA (Vermont)
[2] Norovirus, rehabilitation center - Canada (Regina)
[3] Norovirus, nursing home - USA (Michigan)
[4] Norovirus, increase - USA (Virginia)
[5] Norovirus, prevalence of GGII 4 variant - Europe
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[1] Norovirus, veterans home - USA (Vermont)
Date: Fri 10 Dec 2004
From: ProMED-mail <promed@promedmail.org>
Source: Bennington Banner, Fri 10 Dec 2004 [edited]
<http://www.benningtonbanner.com/Stories/0,1413,104%257E8676%257E2588411,00.html>

Norovirus outbreak shuts down veterans home
-----------------------------------------------
The Vermont Veterans Home is under a health lock down to contain a highly
contagious stomach virus that has stricken 60 residents and employees.
Admissions have been temporarily halted and visitors are being asked to
stay away for at least a week, after a sudden outbreak of "norovirus
infection" hit the 169-bed facility on Tue 7 Dec 2004. About 20 of the 208
staffers, and at least 40 residents, have already become ill. The outbreak
began in the home's dementia wing and spread to other resident halls
quickly, said Commandant Earle Hollings II, head of the state's only
nursing home for veterans. Hollings, on Thu 9 Dec 2004, described the onset
of the virus as violent, "literally you don't know what hit you."
Because the virus is so contagious, it is not uncommon for it to "recycle"
and infect someone again and again, Hollings said. As a precaution,
residents have also been restricted to their wings so that they don't
commingle and infect or re-infect each other or health workers, Hollings
said. The building also is being disinfected "with enough chemical to kill
any bug that crawled through here," he added. It's been particularly hard
on the home's dementia patients, Hollings said. "You and I can handle this,
but when we're talking about the frail and elderly, and they get it again,
it's dangerous as hell. It breaks your heart when you see a dementia
patient get this." Initially, people who get the virus are likely to vomit,
have diarrhea and stomach cramping, which can be quite severe; the symptoms
can last up to 3 days, according to Dr. Paul Jarris, head of the state
Department of Health.
Noroviruses are a group of viruses that cause "stomach flu," or
gastroenteritis, in people. [The International Committee on Taxonomy of
Viruses] has coined norovirus as the new official name for a group of
viruses that includes the Norwalk virus, or "cruise ship virus," that
struck the home last year [2003]. In that episode, Hollings followed the
same health protocol -- temporarily freezing admissions, thorough
disinfection and restricting access to the home -- and the outbreak was
over in several weeks.
Norovirus infection is not usually serious, nor are there long-term health
effects. The most potentially serious side effect is dehydration, which is
more common in the very young and the elderly, according to the CDC.
Noroviruses are present in the stools and vomit of infected people; it can
be transmitted through contaminated foods and drinks, touching surfaces or
objects contaminated with norovirus, or having direct contact with a person
who is infected and showing symptoms, the CDC reports. The virus is not
treatable with medications. The best prevention is frequent hand-washing
and eating only carefully washed fruits and vegetables.
[Byline: Sabina Haskell]
--
ProMED-mail
<promed@promedmail.org>
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[2] Norovirus, rehabilitation center - Canada (Regina)
Date: Mon 13 Dec 2004
From: S. Macbean <s.macbean@sasktel.net>
Source: The Leader-Post (Regina), Mon 13 Dec 2004 [edited]

6 wards at Wascana Rehabilitation Centre closed by norovirus infection
-----------------------------------------------
6 wards at the Wascana Rehabilitation Centre are locked down, after a virus
sickened a number of long-term care residents. Tania Diener, medical health
officer for the Regina Qu'Appelle Health District, says a sample from one
of the sick residents came back positive for norovirus, and precautions
were taken to close the wards.
"It's not anything different from any other outbreak. We get outbreaks in
long-term care facilities from time to time; sometimes it's a respiratory
thing, and sometimes it's a gastric one," she said, adding the health
district has determined the virus isn't food-related, but likely just came
in from the community.
Diener doesn't know how many people fell ill in total, but she says the
situation seems to be improving. In the meantime, staff are keeping close
watch to make sure patients who fall ill don't get dehydrated, especially
since most are elderly or have serious pre-existing health conditions. At
present, residents are kept to their wards, and people with symptoms stay
in their rooms, she said.
[Byline: Jana G. Pruden]
--
S. Macbean
<s.macbean@sasktel.net>
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[3] Norovirus, nursing home - USA (Michigan)
Date: Wed 15 Dec 2004
From: ProMED-mail <promed@promedmail.org>
Source: WLNS.com 6 News, Wed 15 Dec 2004 [edited]
<http://www.wlns.com/Global/story.asp?S=2694802&nav=0RbQUDbp>

Mysterious illness at nursing home identified
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[It was reported on Fri 10 Dec 2004 that seniors at a Troy (Michigan)
nursing home had fallen ill as a result of a mysterious outbreak. One
person has died at the facility, and several others have been hospitalized
because of the illness. (See: Undiagnosed illness, nursing home - USA
(Michigan): RFI 20041211.3280). The following report establishes the
identity of the etiologic agent responsible for the outbreak. - Mod.CP]
State health officials have identified a norovirus among some of the
patients who got sick at a suburban Detroit nursing home last week [2nd
week of December 2004]. One death occurred during the outbreak, but the
cause is still undetermined.
3 samples tested this week from the 15 people who fell ill came back
positive for the gastrointestinal virus. Symptoms of norovirus infection
include nausea, vomiting, diarrhea, dehydration and fever.
--
ProMED-mail
<promed@promedmail.org>
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[4] Norovirus, increase - USA (Virginia)
Date: Tue 21 Dec 2004
From: ProMED-mail <promed@promedmail.org>
Source: 8 News online, Tue 21 Dec 2004 [edited]
<http://www.wric.com/Global/story.asp?S=2718098>

USA: norovirus cases on the increase in Virginia
-----------------------------------------------
The Virginia Department of Health is reporting a rise of norovirus
infection in Virginia. Experts say the gastrointestinal disorder, [also
known as Winter vomiting Disease], occurs most often in the winter.
Symptoms include nausea, vomiting, diarrhea, headache and fever, which
generally last from 2 to 3 days. Doctors say the virus is very contagious.
Children showing symptoms should be kept at home. Experts tell us the virus
has no long term effects.
--
ProMED-mail
<promed@promedmil.org>
******
[5] Norovirus, prevalence of GGII 4 variant - Europe
Date: Wed 22 Dec 2004
From: Harry Vennema <Harry.Vennema@rivm.nl>
Source: Report by: A. Kroneman, H. Vennema, Y. van Duijnhoven, E. Duizer,
and M. Koopmans on behalf of the Food-borne Viruses in Europe Network
(FBVE). [edited]

Large number of norovirus outbreaks associated with a GGII4 variant
-----------------------------------------------
We would like to share an observation from our gastroenteritis outbreak
surveillance, because we suspect a repeat of the situation in 2002, when we
saw a sharp increase in the number of norovirus outbreaks across Europe and
the US. This had a major impact on hospitals and other settings, such as
nursing homes and cruise ships. The stark increase in 2002 was associated
with the introduction of a new variant norovirus within the GGII4 genotype.
This virus was 1st detected early in 2002, and had replaced the resident
virus population by midsummer in all countries in Europe that participate
in the Food-borne Viruses in Europe Network (Lopman et al, 2004; Koopmans
et al, 2003).
In The Netherlands, an increasing number of acute gastroenteritis outbreaks
has been reported over the last 2 months to the National Institute of
Public Health and the Environment (see Table below). The early onset of the
"winter vomiting disease" season, and the large number of reports, are
unusual. Outbreaks have been reported from different settings, but mainly
institutional. So far, all of the outbreaks for which the diagnostic
evaluation has been completed are caused by noroviruses. This situation may
be illustrative for other parts of the world, as several countries have
reported higher incidences recently through ProMed-mail.
In the outbreaks analyzed thus far, again a new lineage (GGII4-2004) within
the GGII4 genotype has been found. This variant is distinct from the
2002 variant strain (GGII4-2002). Since the beginning of August 2004, 71
norovirus outbreaks have been diagnosed in The Netherlands. Of these, 44
were characterized by sequence analysis of the implicated virus. All 44
belong to the new GGII4 lineage. That variant has already been highly
active in Australia during the past winter season [2004] in the southern
hemisphere, as reported by Dr. Michael Lyon (Public Health Virology
Laboratory, Queensland Health Scientific Services, Brisbane, Queensland).
It caused many outbreaks in different settings and has now almost
completely disappeared with the onset of warmer weather.
Since the outbreak season for norovirus in The Netherlands normally starts
in December and peaks in January ("winter vomiting disease"), we think a
warning is in place that a worldwide increase of outbreaks comparable to
2002 might be on its way. In the UK, the cost of the 2002 epidemic was
calculated to be approximately USD 184 million (Lopman et al, 2004).
Although data analysis needs to be finalized, we have indications from the
FBVE surveillance that GGII4 is more commonly associated with outbreaks in
institutional settings than other norovirus variants; this suggests that
the norovirus GGII4 genotype has properties facilitating transmission, and
thereby has the propensity to cause epidemics.
Table: Number of norovirus outbreaks reported in the Netherlands in:
Year / Sep / Oct / Nov / Dec / Jan / Feb / Mar
2000 - 2001 / 3 / 1 / 4 / 3 / 13 / 11 / 8
2001 - 2002 / 2 / 6 / 8 / 14 / 18 / 12 / 8
2002 - 2003 / 7 / 11 / 33 / 52 / 26 / 12 / 2
2003 - 2004 / 1 / 1 / 1 / 2 / 9 / 4 / 3
2004 - 2005 / 9 / 18 / 31 / 13** / - / - / -
**Number of norovirus outbreaks reported in the 1st 2 weeks of December. An
additional 5 outbreaks are under investigation.
Prevention:
-----------
In the literature, some protocols are available for health care settings
(Chadwick J Hosp Infect 2000;45:1-10), hotels and cruise ships. Guidelines
in these protocols are partially evidence-based, partially common sense.
Effectiveness of some of these measures is subject to debate. Therefore,
controlled intervention studies are needed in order to apply evidence-based
practice during outbreaks in institutional settings, especially nursing
homes and homes for the elderly. Until results of such studies are
available, effectiveness in controlling outbreaks is not clear for all
settings.
With these caveats, the following common prevention measures are recommended:
- isolation of affected persons;
- use of gloves and facial masks while cleaning contaminated areas;
- cleaning of contaminated areas with disinfectants containing 1000 [to]
5000 ppm of hypochlorite, carpets with steam (Chadwick et al suggest the
use of hypochlorite at 1000 ppm for disinfection, recent reports do suggest
that this concentration may be too low for efficient inactivation of
noroviruses, and levels of 3000 to 5000 ppm free chlorine may be more
appropriate (Barker et al., 2004; Duizer et al., 2004);
- washing of contaminated bed linen at least at 70 C using detergents
preferably with bleach;
- particular attention to door handles, taps, toilet or bath rails;
- frequent hand washing;
- no return to work until 48-72 hours after compete resolution of symptoms
for affected staff, and education on virus shedding which may continue for
weeks.
We continue to monitor the situation in Europe, and are studying the
difference in virulence between strains, biological background of the
mechanism for its rapid dissemination, and insight into the micro-evolution
of noroviruses. Details on the genetic background of these variant
noroviruses can be obtained by sending an e-mail to <fbve@rivm.nl>. We have
used polymerase gene primers for monitoring purposes, and sequence
properties are given below.
Sequence alignment of norovirus GGII4 lineages: GGII4 cons is the consensus
sequence of strains prevalent before 2002, GGII4 2002 is the consensus
sequence of the strain that was dominant in the 2002/2003 winter season,
GGII4 2004 is the consensus sequence of the strain that has become dominant
during 2004. The sequence is from the RNA dependent RNA polymerase gene,
the region upstream of the conserved YGDD motif. 11 informative positions
in the alignment have been highlighted with an asterisk above the sequence.
In these positions, one sequence is different from the other 2.
....*....| ....|....| ....|....* ....|....|
10 20 30 40
GGII4 cons CAGCCCTAGA AATCATGGTT AAATTCTCCT CAGAACCACA
GGII4 2002 CAGCTCTAGA AATCATGGTT AAATTCTCCT CAGAACCACA
GGII4 2004 CAGCTCTAGA AATCATGGTT AAATTCTCCC CAGAACCACA

....|....| ....|....| ....|....| ....|....|
50 60 70 80
GGII4 cons TTTGGCTCAG GTAGTCGCAG AAGACCTTCT TTCTCCTAGC
GGII4 2002 TTTGGCTCAG GTAGTCGCAG AAGACCTTCT TTCTCCTAGC
GGII4 2004 TTTGGCTCAG GTAGTCGCAG AAGACCTTCT TTCTCCTAGC

....|...*| ....|....| ..*.|....| ....|*...|
90 100 110 120
GGII4 cons GTGGTGGATG TGGGTGACTT CAAAATATCA ATCAATGAGG
GGII4 2002 GTGGTGGATG TGGGTGACTT CACAATATCA ATCAACGAGG
GGII4 2004 GTGGTGGACG TGGGTGACTT CACAATATCA ATCAACGAGG

....*....| ....|.*..| ....|....| ....|....|
130 140 150 160
GGII4 cons GTCTCCCCTC TGGGGTGCCC TGCACCTCCC AATGGAACTC
GGII4 2002 GTCTCCCCTC TGGGGTACCC TGCACCTCCC AATGGAACTC
GGII4 2004 GTCTTCCCTC TGGGGTGCCC TGCACCTCCC AATGGAACTC

....|....| ....|....| ....|....| ....|....|
170 180 190 200
GGII4 cons CATCGCCCAC TGGCTTCTCA CTCTCTGTGC GCTCTCTGAA
GGII4 2002 CATCGCCCAC TGGCTTCTCA CTCTCTGTGC GCTCTCTGAA
GGII4 2004 CATCGCCCAC TGGCTTCTCA CTCTCTGTGC GCTCTCTGAA

....|...** ....*....| ..*.|....| ....|....|
210 220 230 240
GGII4 cons GTTACAAACT TGTCCCCTGA CATCATACAG GCTAATTCCC
GGII4 2002 GTTACAAATC TGTCCCCTGA CATCATACAG GCTAATTCCC
GGII4 2004 GTTACAAACT TGTCTCCTGA CACCATACAG GCTAATTCCC
References (alphabetical order):
------------------------------
Barker J, Vipond IB, Bloomfield SF. Effects of cleaning and disinfection
in reducing the spread of Norovirus contamination via environmental
surfaces. J Hosp Infect. 2004 Sep;58(1):42-9.
Chadwick PR et al. Management of hospital outbreaks of gastro-enteritis due
to small round structured viruses. Journal of Hospital Infection 2000:45:1-10.
Duizer E, Bijkerk P, Rockx B, De Groot A, Twisk F, Koopmans M. Inactivation
of caliciviruses. Appl Environ Microbiol. 2004 Aug;70(8):4538-43.
Koopmans M et al; European Consortium on Foodborne Viruses. Early
identification of common-source foodborne virus outbreaks in Europe. Emerg
Infect Dis. 2003;9:1136-42.
Lopman BA et al for the European Food-borne viruses Network. Increase in
viral gastroenteritis outbreaks in Europe and epidemic spread of new
norovirus variant. Lancet, 2004;363(9410):682-8.
Lopman BA et al. Epidemiology and cost of nosocomial gastroenteritis, Avon,
England, 2002-2003. Emerg Infect Dis. 2004;10:1827-34.
--
Harry Vennema PhD
Scientist Virology
Diagnostic Laboratory for Infectious Diseases and Perinatal Screening
National Institute for Public Health and the Environment
PO Box 1, 3720 BA, Bilthoven
Netherlands
<Harry.Vennema@rivm.nl>

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