A large nontypical outbreak of Norwalk virus. Gastroenteritis associated with exposing celery to nonpotable water and with Citrobacter freundii.

The US Air Force Academy experienced a point-source outbreak of gastroenteritis originally believed to be caused by Salmonella. The overall attack rate was 48% among approximately 3000 cadets and staff. Food-specific attack rates implicated chicken salad. The odds ratio for chicken salad consumption in ill cadets was 10.7 (95% confidence interval: 8.2; 13.8). The celery component had been exposed to nonpotable water. Citrobacter freundii were statistically associated with consumption of the suspected vehicle and subsequent illness. Most aspects were consistent with the epidemiology of Norwalk gastroenteritis. However, the clinical presentation was not typical of reported outbreaks. One hundred five cadets required intravenous rehydration. Serum samples implicated Norwalk virus as the most probable cause of this outbreak. The Centers for Disease Control (Atlanta, Ga) recently began national surveillance for viral gastroenteritis. All outbreaks of gastroenteritis associated with nonpotable water should be investigated for evidence of viral cause.     

Serological responses among teenagers after natural exposure to Norwalk virus

Twenty-one teenagers exposed to a contaminated water supply during an outbreak of gastroenteritis were tested for seroconversion to Norwalk virus. Serum specimens were collected within 72 hr of exposure and four weeks later. Each of the 11 individuals who developed symptoms and five of the 10 who remained well had a whole-antibody response in serum. None of the remaining five teenagers became ill or seroconverted. Neither seroconversion nor susceptibility to illness was associated with an absence of detectable antibody from acute-phase serum specimens. These findings support the view that immunity to Norwalk virus is not determined by serum antibody. Furthermore, the results are consistent with the possibility, suggested by previous studies in volunteers, that susceptibility is determined by Norwalk virus-specific intestinal receptor sites. IgM responses to the Norwalk virus were detected in only seven persons who became ill (64%) and nine who seroconverted (56%). The seroassay for the Norwalk IgM component might have proved a more sensitive diagnostic tool in this outbreak if convalescent-phase specimens had been collected sooner than four weeks after the onset of illness.     

Pattern of shedding of the Norwalk particle in stools during experimentally induced gastroenteritis in volunteers as determined by immune electron microscopy.

In 11 of 23 volunteers the Norwalk virus-like particle was visualized by immune electron microscopy in at least one stool specimen obtained during the acute phase of experimentally induced nonbacterial gastroenteritis. Examination of multiple stool specimens obtained during the course of illness in these 11 volunteers revealed maximal concentration of Norwalk virus-like particle at the onset of illness and shortly thereafter; in no case was the Norwalk particle visualized in stools obtained before the onset of illness. This finding further suggests that the Norwalk particle was the etiological agent of the Norwalk gastroenteritis outbreak. The limit of reliability of our immune electron microscopy assay system for particle counting was examined.     

A 27-nm virus isolated during an outbreak of acute infectious nonbacterial gastroenteritis in a convalescent hospital: a possible new serotype

An outbreak of acute infectious nonbacterial gastroenteritis began among elderly patients in a convalescent hospital in Marin County in northern California in March 1978 and persisted through May 1978. The overall clinical attack rate was 51% of 187 residents and 12% of 180 employees. A 27-nm viruslike particle was observed by immune electron microscopy in stools obtained at or near the onset of illness from four of 32 patients. Seroresponses to the 27-nm particles were found by immune electron microscopy in 16 of 18 patients. In addition, serologic evidence of infection with this or a related agent was demonstrated in persons who developed illness in another large outbreak of acute infectious nonbacterial gastroenteritis which occurred in a nearby county. This agent is morphologically similar to but serologically unrelated to the Norwalk and Hawaii gastroenteritis agents and has been designated the Marin agent pending further classification.     

Norwalk virus in Norway: an outbreak of gastroenteritis studied by electron microscopy and radioimmunoassay

An outbreak of acute gastroenteritis affected approximately half of 40 children staying at a holiday centre in Southern Norway. By direct electron microscopy Norwalk-like viruses were demonstrated in 4/8 available stool specimens. No other pathogens were detected. Antibody against these viruses was demonstrated by immune electron microscopy in all of 7 convalescent phase sera but in none of 11 acute phase sera collected. Radioimmunoassay examination showed a rise in titre of Norwalk virus antibody in 6 available paired sera. This outbreak of Norwalk virus gastroenteritis in Norway was thus documented by a combined use of direct and immune electron microscopy and radioimmunoassay.     

A predominant role for Norwalk-like viruses as agents of epidemic gastroenteritis in Maryland nursing homes for the elderly.

Stool specimens from 156 Maryland nursing home residents, who became ill during 20 outbreaks of gastroenteritis from November 1987 through February 1988, were analyzed. All tested negative for astroviruses, enteroviruses, Group A rotaviruses, Sapporo-like caliciviruses, and enteric bacteria (i.e., Salmonella, Clostridium, and Shigella species). Eighty-two (52%) were positive for Norwalk-like viruses (NLVs), members of the family Caliciviridae. Six distinct genetic clusters within genogroups I and II of the NLVs were detected; a genogroup II (GII) virus closely related to the Camberwell virus in the NLV GII/4 genetic cluster was the predominant strain. Serologic evidence of infection with > or = 1 NLV was detected in 61 (56%) of 109 patients tested against 3 NLV antigens (i.e., Norwalk, Hawaii, and Toronto viruses). Sixteen (80%) outbreaks met the definition for an NLV outbreak. Taken together with a retrospective analysis of bacterial gastroenteritis in this same setting, these data support a major role for NLVs as etiologic agents of gastroenteritis in elderly persons.     

Sapporo virus: history and recent findings

Morphologically distinct caliciviruses of human origin were first found in stools of children with gastroenteritis in 1976. Sapporo virus, or human calicivirus Sapporo, with typical surface morphology was first detected during a gastroenteritis outbreak in a home for infants in Sapporo, Japan, in 1977. Since then, morphologically and antigenically identical virus has been detected frequently in the same institution in association with outbreaks of gastroenteritis. Sapporo virus is widely distributed worldwide, as evidenced by the appearance of antigenically or genetically similar viruses and seroepidemiologic findings. Sapporo virus plays an important role in outbreaks of infantile gastroenteritis and is less important in foodborne outbreaks. Sapporo virus has been approved as the type species of the genus "Sapporo-like viruses in the family Caliciviridae. The history of and recent findings, as obtained by newly developed techniques, about Sapporo viruses are presented.     

Role of Norwalk virus in outbreaks of nonbacterial gastroenteritis.

Twenty-five separate outbreaks of nonbacterial gastrointestinal illnesses were studied serologically for evidence of infection with the Norwalk virus and the rotaviruses that affect humans. Eight of 25 outbreaks appeared to be related to the Norwalk virus. In one of the 25 outbreaks, there was evidence of rotavirus infection. These observations suggest that the Norwalk virus or serologically related agents play an important role in epidemic nonbacterial gastroenteritis in adults and older children.     

The impact of foodborne calicivirus disease: the Minnesota experience

The first outbreaks of Norwalk virus gastroenteritis in Minnesota were confirmed in 1982. Since then, Norwalk-like caliciviruses have been recognized to be the most common cause of foodborne disease outbreaks, accounting for 41% of all confirmed foodborne outbreaks in Minnesota from 1981-1998. Although laboratory confirmation of caliciviruses in stool samples was not attempted in most of these outbreaks, all conformed to epidemiologic criteria for defining outbreaks of Norwalk virus. Since 1996, the availability of polymerase chain reaction testing at the Minnesota Department of Health has allowed for the confirmation of calicivirus infection among patients involved in epidemiologically defined outbreaks of viral gastroenteritis. Results have confirmed the usefulness of characterizing foodborne disease outbreaks by epidemiologic criteria and also confirmed the importance of human caliciviruses as the leading cause of foodborne disease outbreaks in Minnesota.     

Diagnosis of astrovirus gastroenteritis by antigen detection with monoclonal antibodies

An enzyme-linked immunosorbent assay (ELISA), based on monoclonal antibodies to the astrovirus group antigen, was designed for the detection of astroviruses in stools of patients with gastroenteritis. Compared to immune electron microscopy used as the standard test, the sensitivity of the astrovirus ELISA was 91% (31/34) and the specificity was 96% (54/56). All five of the known astrovirus serotypes could be detected in 16 samples on which serotyping was done. In tests on 155 stools containing other enteric viruses, including adenoviruses, rotaviruses, caliciviruses, Hawaii virus, Snow Mountain virus, and Norwalk virus (30, 20, 70, 24, 4, and 7 samples, respectively), only 3 were positive in the astrovirus ELISA. The combined specificity for all astrovirus immune electron microscopy-negative samples was 98% (206/211). The results demonstrate that the new ELISA provides a sensitive and specific means for the diagnosis of astrovirus gastroenteritis.     

Two sequential outbreaks of rotavirus gastroenteritis: evidence for symptomatic and asymptomatic reinfections

In two sequential outbreaks of rotavirus gastroenteritis that occurred in a kibbutz in southern Israel (the Negev), 32 persons (9% of the population) were ill in the first and 45 (13% of the population) in the second. Excretion of virus, changes in titers of rotavirus-specific serum IgG, or both implicated rotavirus in 72% of the illnesses in outbreak 1 and in 56% of the illnesses in outbreak 2. In both outbreaks the age-specific morbidity rate decreased with increasing age. Half (six of 12) of the children six to 27 months of age who were ill with rotavirus in outbreak 1 were ill with rotavirus again in outbreak 2, whereas two were asymptomatically infected; older children who were ill in outbreak 1 were not ill in outbreak 2. Serotype determination by enzyme-linked immunosorbent assay using monoclonal antibodies to VP7 implicated a serotype 3 virus in outbreak 1 and a serotype 1 virus in outbreak 2.     

A multistate outbreak of Norwalk virus gastroenteritis associated with consumption of commercial ice.

Between 19 and 27 September 1987, a cluster of outbreaks of gastrointestinal illness occurred among persons who had attended a museum fund-raiser in Wilmington, Delaware and an intercollegiate football game in Philadelphia. A survey of four groups attending these events showed that 31% (191/614) became ill. Altogether, those who consumed ice were 12 times more likely to experience either vomiting or diarrhea than those who did not (attack rate, 55% vs. 4%, P less than .001). Ice consumed at the events was traced to a manufacturer in southeastern Pennsylvania whose wells had been contaminated when flooded by a nearby creek after a torrential rainfall on 8 September. Of 19 affected persons tested within 1 week of exposure, 13 (68%) had at least a fourfold rise in antibody titer to the Norwalk virus. This report, the first to document an association of contaminated commercial ice with Norwalk gastroenteritis should prompt reassessment of government regulation of the production and distribution of ice.     

Detection by immune electron microscopy of 26- to 27-nm viruslike particles associated with two family outbreaks of gastroenteritis.

Viruslike particles 26-27 nm in size were detected by immune electron microscopy in stools of volunteers who were ill after administration of bacteria-free fecal filtrates derived from two separate family outbreaks of acute epidemic nonbacterial gastroenteritis. Fluorocarbon treatment and concentration of the filtrates were necessary to provide enough antigen to test sera by immune electron microscopy. Serum antibody responses were detected in both naturally occurring and experimentally induced cases of illness. The Montgomery County viruslike particle appeared to be related to the previously described Norwalk particle, whereas the Hawaii particle appeared to be unrelated to the Norwalk particle.     

Acute gastroenteritis outbreak caused by a GII.6 norovirus

AIM:To report an acute gastroenteritis outbreak caused by a genogroup 2 genotype 6(GII.6) strain norovirus in Shanghai,China.METHODS:Noroviruses are responsible for approximately half of all reported gastroenteritis outbreaks in many countries.Genogroup 2 genotype 4 strains are the most prevalent.Rare outbreaks caused by GII.6 strains have been reported.An acute gastroenteritis outbreak occurred in an elementary school in Shanghai in December of 2013.Field and molecular epidemiologic investigations were conducted.RESULTS:The outbreak was limited to one class in an elementary school located in southwest Shanghai.The age of the students ranged from 9 to 10 years.The first case emerged on December 10,2013,and the last case emerged on December 14,2013.The cases peaked on December 11,2013,with 21 new cases.Of 45 students in the class,32 were affected.The main symptom was gastroenteritis,and 15.6%(5/32) of the cases exhibited a fever.A field epidemiologic investigation showed the pathogen may have been transmitted to the elementary school from employees in a delicatessen via the first case student,who had eaten food from the delicatessen one day before the gastroenteritis episodes began.A molecular epidemiologic investigation identified the cause of the gastroenteritis as norovirus strain GII.6;the viral sequence of the student cases showed 100% homology with that of the shop employees.Genetic relatedness analyses showed that the new viral strain is closely related to previously reported GII.6 sequences,especially to a strain reported in Japan.CONCLUSION:This is the first report to show that norovirus strain GII.6 can cause a gastroenteritis outbreak.Thus,the prevalence of GII.6 noroviruses requires attention.     

Norovirus outbreak among primary schoolchildren who had played in a recreational water fountain

BACKGROUND: A gastroenteritis outbreak was associated with playing in a norovirus-contaminated recreational fountain. OBJECTIVE AND STUDY DESIGN: A retrospective cohort study was performed to estimate the magnitude of the outbreak and identify its source. Epidemiological investigation included standardized questionnaires about sex, age, school, class, risk exposures, and illness characteristics. Stool samples and environmental water samples were analyzed for the presence of bacteria, viruses, and parasites. RESULTS: Questionnaires were returned for 191 schoolchildren (response rate, 83%) with a mean age of 9.2 years, of whom 47% were ill (diarrhea and/or vomiting). Children were more likely to have been ill if they had played in the recreational fountain (relative risk, 10.4). Norovirus (Birmingham) was detected in 22 (88%) stool specimens from ill children and in 6 (38%) specimens from healthy children. The water sample from the fountain contained a norovirus strain that was identical to the RNA sequence found in stools. CONCLUSIONS: Recreational water may be the source of gastroenteritis outbreaks. Adequate water treatment can prevent these types of outbreak.     

The clinical features of infantile gastroenteritis due to rotavirus.

The symptoms of 100 hospitalised cases of rotavirus infantile gastroenteritis are described. Most patients presented with high fever between the 2nd and 5th day, having started with diarrhoea or vomiting or both. 42% of the infants had upper respiratory tract symptoms. Severe electrolyte disturbance did not occur, although there was a suggestion of a correlation between the higher blood ureas and the number of rotavirus particles in the stools. The mean duration of illness of uncomplicated cases was 13.4 days. Infants were more severely affected when enteropathic coliforms were also present, the total duration of illness being extended to 23 days. It is suggested that rotavirus or similar virus infection may be an essential precursor in the majority of coliform gastroenteritis.     

The discovery of the 27-nm Norwalk virus: an historic perspective

In 1972, a 27-nm virus-like particle was discovered by use of immune electron microscopy (IEM) in an infectious stool filtrate derived from an outbreak of gastroenteritis in an elementary school in Norwalk, Ohio. IEM enabled the direct visualization of antigen-antibody interaction, as the particles were aggregated and coated by specific antibodies. This allowed the recognition and identification of a 27-nm virus-like particle that did not have a distinctive morphology, was low-titered, and was among the smallest viruses known. Serum antibody responses to the 27-nm particle were demonstrated in key individuals infected under natural or experimental conditions; this and other evidence suggested that this virus-like particle was the etiologic agent of the Norwalk gastroenteritis outbreak. The fastidious 27-nm Norwalk virus is now considered to be the prototype strain of a group of noncultivatable viruses that are important etiologic agents of epidemic gastroenteritis in adults and older children.