120 sick: California wildfire evacuees face the misery of norovirus

The European Cleaning Journal reports that more than 120 people forced to flee the deadly California wildfires are now battling the norovirus to add to their woes.

Sick evacuees are being housed in separate shelters and active monitoring of all shelter residents is being carried out. Meanwhile, separate washrooms are being allocated to the ill and protective equipment is being supplied to medical staff.

Outbreaks of the norovirus is not uncommon in situations where hundreds of people live in close quarters, says public information officer for Butte County Public Health Lisa Almaguer. The health department is working with the Red Cross plus state and federal partners to reduce the spread of the illness.

One evacuee claims to have seen someone “puking into a toilet”, adding that health officials were urging all evacuees to wash their hands repeatedly, avoid handshakes and to use hand sanitiser before eating.

Clemson researchers target vomit cleanup methods in new norovirus research

Ever since that time in 2008 when one of Amy’s French students barfed in class, we’ve sorta been obsessed with, what is the proper way to clean up barf?

Especially if norovirus is involved.

The previous story gives an idea of just how infectious this stuff is.

Two Clemson researchers who are working with the federal government to combat stomach bug outbreaks among the elderly are convinced that advancements in this field could be lifesaving. 

Clemson University professors Angela Fraser and Xiuping Jiang catered their new norovirus research project to the needs of residents in long-term care facilities.

“I just think that those of us who are fortunate need to look out for those who are vulnerable,” Fraser said. “And this is a vulnerable population.”

One of the main goals of their new project, which recently received more than $1 million in funding from the federal Agency for Healthcare Research and Quality, is to come up with easy-to-implement, cost-efficient and effective vomit cleanup procedures for soft surfaces. The hope is that this will directly combat the high percentage of norovirus outbreaks in long-term care facilities and places with similar environments. 

The study, which has funding for three years, will be done in partnership with the Centers for Disease Control and Prevention, Emory University and the University of Illinois-Chicago.

In past studies on proper vomit cleanup, Fraser and Jiang learned that there were gaps in the research, particularly when it came to the proper disinfectant to use on soft services to prevent the spread of diseases.

Chlorine bleach, the most commonly used disinfectant, mainly worked on hard surfaces and could rarely be used on soft surfaces like carpets and couches. One of the areas they realized could benefit the most from this information was long-term care facilities. 

“Long-term facilities want to create a very homelike environment, so they have lots of carpet around in comparison to hospitals and other environments,” Jiang said.

They also, of course, tend to have a high number of older adults.

“That’s people’s living environment,” Fraser said. “Do you really want people to be living where everything is just cinder block or smooth walls?”

She said because older patients are more likely to have chronic diseases, their immune systems are typically weakened as well. This means that when these older adults get infected with diseases like the norovirus, there can be a more severe expression of the disease compared to someone younger. Because of all of these factors, some view the study as even more imperative.

 

Multiple modes of transmission during a Thanksgiving Day Norovirus outbreak, 2017

The U.S. Centers for Disease Control reports on November 28, 2017, the manager of restaurant A in Tennessee reported receiving 18 complaints from patrons with gastrointestinal illness who had dined there on Thanksgiving Day, November 23, 2017. Tennessee Department of Health officials conducted an investigation to confirm the outbreak, assess exposures, and recommend measures to prevent continued spread.

On November 23, one patron vomited in a private dining room, and an employee immediately used disinfectant spray labeled as effective against norovirus* to clean the vomitus. After handwashing, the employee served family-style platters of food and cut pecan pie. For the November 23 Thanksgiving Day, restaurant A served 676 patrons a limited menu from 11 a.m. to 8 p.m. The manager provided contact information, seating times, and seating locations for 114 patrons with reservations. All patrons with contact information were telephoned, and a questionnaire was used to assess illness and exposures for anyone living in the household who ate at restaurant A on November 23. Stool specimens were requested from ill patrons. Among the 676 patrons, 137 (20%) were enrolled in a case-control study.

A probable case was defined as diarrhea (three or more loose stools in 24 hours) or vomiting within 72 hours of eating at restaurant A on November 23; probable cases with norovirus RNA detected in a stool specimen by real-time reverse transcription–polymerase-chain reaction (RT-PCR) were considered confirmed. On November 30, environmental swabs for norovirus testing were collected in the restaurant. Patient and environmental samples were tested by real-time RT-PCR and sequenced at the Tennessee State Public Health Laboratory.

Thirty-six (26%) case-patients (two confirmed and 34 probable) and 101 (74%) controls were enrolled in the case-control study. Illness onsets occurred during November 23–25, with 17 of 35 (49%) cases occurring on November 24. The mean incubation period was 31 hours (range = 2.5–54.5 hours), and the mean illness duration was 3 days (range = 0–6 days). Only one case-patient sought medical care. Diarrhea was reported by 33 (94%) case-patients, fatigue by 29 (83%), nausea and abdominal cramps by 28 (80%), vomiting by 24 (69%), and fever by six (17%).

Among menu items, only pecan pie was significantly associated with illness (odds ratio [OR] = 2.6; 95% confidence interval [CI] = 1.1–5.8); however, it was eaten by only 16 (47%) of 34 case-patients. The vomiting event occurred around noon; patrons seated during 11 a.m.–1 p.m. were significantly more likely to become ill than were patrons seated during other times (OR = 6.0; 95% CI = 2.6–15.3). No significant differences between dining locations (i.e., private dining room versus general seating) were identified (OR = 1.4; 95% CI = 0.4–4.3). Logistic regression was used to evaluate the effects of eating pecan pie, seating time, and seating location; only seating time during 11 a.m.–1 p.m. remained statistically significant (OR = 6.0; 95% CI = 2.2–16.5).

Stool specimens from two case-patients identified Norovirus GII.P16-GII.4 Sydney. Norovirus GII was identified in one environmental swab collected from the underside of a table leg adjacent to the vomitus.

A point-source norovirus outbreak occurred after an infected patron vomited in a restaurant. Transmission near the vomiting event likely occurred by aerosol or fomite. Norovirus spread throughout the restaurant could have occurred by aerosol, person-to-person, fomite, or foodborne routes. Inadequate employee handwashing likely facilitated foodborne transmission through servings of pecan pie.

In hospital settings, CDC and the Tennessee Department of Health recommend contact precautions (e.g., gloves and gowns) when personnel have contact with vomitus (1). Similarly, the Food and Drug Administration’s 2017 Food Code recommends restaurants have a written plan detailing when and how employees should use personal protective equipment for cleaning vomitus (2). Reinforcing the need for proper handwashing and performing thorough environmental cleaning with appropriate personal protective equipment in food service establishments can prevent or mitigate future outbreaks.

Acknowledgments

Teresa Vantrease, Jana Tolleson, Tiffany Rugless, Lee Wood, Anita Bryant-Winton, Heather Mendez, Jeannette Dill, Alan Pugh, Jason Pepper, Katie Nixon, Marcy McMillian, Jane Yackley; FoodCORE Interview Team; staff members from restaurant A.

Corresponding author: Julia Brennan, JBrennan@cdc.gov, 615-253-9971.

1Epidemic Intelligence Service, CDC; 2Division of Scientific Education and Professional Development, CDC; 3Communicable and Environmental Diseases and Emergency Preparedness, Tennessee Department of Health; 4Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee.

All authors have completed and submitted the ICMJE form for disclosure of potential conflicts of interest. William Schaffner reports personal fees from Pfizer, Merck, Dynavax, Seqirus, SutroVax, and Shionogi, outside the submitted work. No other potential conflicts of interest were disclosed.

* Active ingredients = n-Alkyl dimethyl benzyl ammonium chlorides and n-Alkyl dimethyl ethylbenzyl ammonium chlorides.

The cost of Norovirus in Germany

We estimated numbers of hospitalizations for norovirus gastroenteritis (NGE) and associated medical costs in Germany, where norovirus testing is high because reimbursement is affected. We extracted aggregate data for patients hospitalized with a primary or secondary code from the International Classification of Diseases, 10th Revision (ICD-10), NGE diagnosis during 2007–2012 from the German Federal Statistics Office.

We assessed reliability of the coding system in patient records from a large academic hospital. Approximately 53,000–90,000 NGE hospitalizations occurred annually in Germany (21,000–33,000 with primary and 32,000–57,000 with secondary ICD-10–coded NGE diagnoses). Rates of hospitalization with NGE as primary diagnosis were highest in children <2 years of age; rates of hospitalization with NGE as secondary diagnosis were highest in adults >85 years of age. The average annual reimbursed direct medical cost of NGE hospitalizations was €31–43 million. Among patients with a NGE ICD-10 code, 87.6% had positive norovirus laboratory results.

Norovirus Gastroenteritis among Hospitalized Patients, Germany, 2007–2012

Kowalzik, F., Binder, H., Zöller, D., Riera-Montes, M., Clemens, R., Verstraeten, T….Zepp, F. (2018). Norovirus Gastroenteritis among Hospitalized Patients, Germany, 2007–2012. Emerging Infectious Diseases, 24(11), 2021-2028. https://dx.doi.org/10.3201/eid2411.170820.

https://wwwnc.cdc.gov/eid/article/24/11/17-0820_article

Travel-related foodborne illness

A few years ago, my family and I embarked on a trip an all-inclusive resort in Mexico, a little get away from the hectic day to day musings in our lives. First day I decided to go for a jog  and was bitten by a wild dog travelling in a pack. I was shipped off to Cancun to start rabies postexposure prophylaxis. Second day, contracted norovirus. Third day almost left.

Colette Crampsey of the The Daily Record reports:

Reece Russell and John English both fell ill after eating at all-inclusive resorts in Cancun.
Two holidaymakers have told of their ordeals after being crippled by food poisoning bugs in Mexico.
Reece Russell, 28, was infected with salmonella, which led to inflammation around his heart.
And John English, 51, ended up in hospital with bacterial gastritis. He has been left with long-term health problems and has had to give up being a football coach.
Both men fell ill after travelling to all-inclusive resorts in Cancun.
Reece, from Dunfermline, went to the resort with his parents and sister in June.
He said: “About a week after I came home, I started falling very ill. I woke up at 1am with chest pains. In hospital, a blood test showed I had a high level of protein in my blood caused by possible heart attacks.”
Reece was diagnosed with myopericarditis –inflammation of the membrane and muscle around the heart. Tests showed salmonella was to blame.
He said: “The doctors implied that if I hadn’t gone to hospital when I did, it would have been significantly worse.” 
Engineer Reece, who stayed at the Bahia Principe, had to miss two weeks of work. He is seeking compensation from travel firm TUI.
John stayed at Moon Palace hotel with wife Janice and their two children in July.
After eating at a Brazilian restaurant, the Scottish Gas worker was violently sick and was whisked to hospital.
John said: “They told me my magnesium levels were very low. If that happens, your organs can shut down and you can die. It was quite frightening.”
The couple had to fork out £4000 for treatment and a further £1500 on John’s release the next day.
He said: “I’ve lost 2st and doctors have told me my blood pressure is through the roof. I could be on tablets for the rest of my life.
“I’m having to give up football coaching, which is very hard for me.”
A Thomas Cook spokesman said: “We are sorry to hear Mr English became ill. We advise customers to tell their rep or hotel staff immediately if they are unwell so they can get the right support.”
A spokesman for TUI said: “We will be contacting Mr Russell directly to review the matter.
“We regularly audit all of the hotels we feature in respect of health and safety, including hygiene.”

‘We’re trying to stay healthy and look good on stage and everyone’s throwing up around us’ (Probably) Norovirus spreads at Miss Nevada pageant

Faith Tanner of Fox 5 reports that health officials have been investigating a suspected norovirus outbreak at Westgate Las Vegas Resort and Casino.

At the end of June, families from across the state stayed at Westgate for the Miss Nevada pageant. 

Contestants said several people got sick during and after the competition. 

“It’s terrifying, because we’re all trying to stay healthy and look good on stage and everyone’s throwing up around us,” Macie Tuell said. 

It was a week Miss Lake Tahoe, Macie Tuell, prepared all year for, to compete in Miss Nevada at the Westgate in Las Vegas. 

But Tuell and the other contestants weren’t prepared for so many people to get sick. 

“The first girl in our group that got sick, it happened Wednesday night and then each day a couple more girls got sick and a couple more got sick the day after that. I know one girl actually got sick while she was on stage and had to run off,” Tuell said. 

She said the show went on and contestants pulled through. Tuell ended up getting first runner up. It wasn’t until the end of the pageant that most contestants learned how widespread the illness was. 

“A couple of the employees were getting sick, so that’s when we stared to figure out it wasn’t just our group. Even our family members who we had not seen at that point they were getting sick.”

The Southern Nevada Health District has been investigating. 

Their information so far suggested a gastrointestinal illness. Consistent with norovirus or the stomach flu. Health officials couldn’t confirm how many people got sick. 

Officials said they’ve surveyed the Westgate’s kitchens and on July 4, the resort agreed to close the buffet for an additional health assessment. 

That ole swimmin’ hole got lotsa bugs in it

Untreated recreational water–associated outbreaks can be caused by pathogens, toxins, or chemicals in freshwater (e.g., lakes) or marine water (e.g., ocean).

During 2000–2014, 140 untreated recreational water–associated outbreaks that caused at least 4,958 illnesses and two deaths were reported; 80 outbreaks were caused by enteric pathogens.

Swimmers should heed posted advisories closing the beach to swimming; not swim in discolored, smelly, foamy, or scummy water; not swim while sick with diarrhea; and limit water entering the nose when swimming in warm freshwater.

Outbreaks associated with untreated recreational water can be caused by pathogens, toxins, or chemicals in fresh water (e.g., lakes, rivers) or marine water (e.g., ocean). During 2000–2014, public health officials from 35 states and Guam voluntarily reported 140 untreated recreational water–associated outbreaks to CDC. These outbreaks resulted in at least 4,958 cases of disease and two deaths. Among the 95 outbreaks with a confirmed infectious etiology, enteric pathogens caused 80 (84%); 21 (22%) were caused by norovirus, 19 (20%) by Escherichia coli, 14 (15%) by Shigella, and 12 (13%) by Cryptosporidium. Investigations of these 95 outbreaks identified 3,125 cases; 2,704 (87%) were caused by enteric pathogens, including 1,459 (47%) by norovirus, 362 (12%) by Shigella, 314 (10%) by Cryptosporidium, and 155 (5%) by E. coli. Avian schistosomes were identified as the cause in 345 (11%) of the 3,125 cases. The two deaths were in persons affected by a single outbreak (two cases) caused by Naegleria fowleri. Public parks (50 [36%]) and beaches (45 [32%]) were the leading settings associated with the 140 outbreaks. Overall, the majority of outbreaks started during June–August (113 [81%]); 65 (58%) started in July. Swimmers and parents of young swimmers can take steps to minimize the risk for exposure to pathogens, toxins, and chemicals in untreated recreational water by heeding posted advisories closing the beach to swimming; not swimming in discolored, smelly, foamy, or scummy water; not swimming while sick with diarrhea; and limiting water entering the nose when swimming in warm freshwater.

Outbreaks associated with untreated recreational water-United States, 2000-2014

29.jun.18

CDC

Daniel S. Graciaa, MD1; Jennifer R. Cope, MD2; Virginia A. Roberts, MSPH2; Bryanna L. Cikesh, MPH2,3; Amy M. Kahler, MS2; Marissa Vigar, MPH2; Elizabeth D. Hilborn, DVM4; Timothy J. Wade, PhD4; Lorraine C. Backer, PhD5; Susan P. Montgomery, DVM6; W. Evan Secor, PhD6; Vincent R. Hill, PhD2; Michael J. Beach, PhD2; Kathleen E. Fullerton, MPH2; Jonathan S. Yoder, MPH2; Michele C. Hlavsa, MPH2

https://www.cdc.gov/mmwr/volumes/67/wr/mm6725a1.htm?s_cid=mm6725a1_e

‘Hellish’ gastro outbreak sends more than 1,000 people to emergency in Australia

The Sunshine Coast is an idyllic spot on the Pacific Ocean, about an hour north of Brisbane.

But according to Shri Rajen of the Daily Mail a huge, and unidentified gastro outbreak has left more than 1,000 people in hospital. 

Emergency departments in the Sunshine Coast, Queensland, were flooded with 1142 patients with gastroenteritis.

Around 600 cases were treated at the Sunshine Coast University Hospital.

Gastroenteritis can be either infectious or non-infectious, public health physician said, Dr Andrew Langley, reported The Sunshine Coast Daily.

He said, usually bacteria, parasites and viruses are the cause of infectious cases.

‘Noroviruses are a very common cases of viral gastroenteritis. Causes of norovirus are not routinely reported to Queensland Health,’ Dr Langley said.

‘If you have gastroenteritis, you should not return to work until diarrhoea has ceased. Children should not return to childcare or school until diarrhoea has ceased for 24 hours,’ said Dr Langley.

Last month, a gastro outbreak has forced Mt Maria College in Brisbane to close after 20 students and two teachers were sent to hospital with vomiting and diarrhoea.

Last year nearly 2000 people admitted themselves to hospitals across Sydney.

Gastroenteritis can be easily passed from person to person due to its highly infectious nature.

Norovirus inside leafy greens

Lettuce has been implicated in human norovirus (HuNoV) outbreaks. The virus is stable on the leaf surface for at least 2 weeks; however, the dynamics of virus internalization have not been fully investigated. The purpose of this study was to assess the internalization and distribution of HuNoV and two surrogate viruses, porcine sapovirus (SaV) and Tulane virus (TV), in lettuce and spinach.

Viral inoculations through the roots of seedlings and the petiole of leaves from mature plants were performed, and the viruses were tracked on days 1 and 6 post-root inoculation and at 16 h and 72 h post-petiole inoculation. Confocal microscopy was used to visualize root-internalized HuNoV.

In both lettuce and spinach, (i) HuNoV was internalized into the roots and leaves at similar RNA titers, whereas surrogate viruses were more restricted to the roots, (ii) all three viruses were stable inside the roots and leaves for at least 6 days, and (iii) HuNoV disseminated similarly inside the central veins and leaf lamina, whereas surrogate viruses were more restricted to the central veins. Infectious TV, but not SaV, was detectable in all tissues, suggesting that TV has greater stability than SaV. HuNoV was visualized inside the roots’ vascular bundle and the leaf mesophyll of both plants.

In conclusion, using surrogate viruses may underestimate the level of HuNoV internalization into edible leaves. The internalization of HuNoV through roots and cut leaves and the dissemination into various spinach and lettuce tissues raise concerns of internal contamination through irrigation and/or wash water.

IMPORTANCE Human noroviruses are the leading cause of foodborne outbreaks, with lettuce being implicated in the majority of outbreaks. The virus causes acute gastroenteritis in all age groups, with more severe symptoms in children, the elderly, and immunocompromised patients, contributing to over 200,000 deaths worldwide annually. The majority of deaths due to HuNoV occur in the developing world, where limited sanitation exists along with poor wastewater treatment facilities, resulting in the contamination of water resources that are often used for irrigation.

Our study confirms the ability of lettuce and spinach to internalize HuNoV from contaminated water through the roots into the edible leaves. Since these leafy greens are consumed with minimal processing that targets only surface pathogens, the internalized HuNoV presents an added risk to consumers. Thus, preventive measures should be in place to limit the contamination of irrigation water. In addition, better processing technologies are needed to inactivate internalized viral pathogens.

Tissue distribution and visualization of internalized norovirus in leafy greens

April 2018

Applied Environmental Microbiology, vol.84 no.12

Malak A. EsseiliaTea MeuliabLinda J. Saifa and Qiuhong Wanga

 doi:10.1128/AEM.00292-18

http://aem.asm.org/content/84/12/e00292-18.abstract?etoc

From the (written) barf: Goodbye Jimmy-self-serve buffet on Holland America cruises

Holland America cruise line has all but put an end to the self-serve buffet.

Darren Cartwright of Yahoo News writes the Holland America Line has literally taken a hands-on, or make that hands-off, approach and heavily restricted self-service in the general dining areas of its ships.

The move could be just what’s needed to restore Australia’s faith in the industry following four gastro outbreaks on Holland America’s sister line Princess Cruises over the past 15 months.

The most recent was in January when some 200 passengers went down with the norovirus aboard the Sea Princess during a tour of New Zealand.

Both Holland America and Princess are subsidiaries of the Carnival Corporation, which has a number of cruise lines including P&O Australia and Cunard.

I take a tour around Asia on Holland America’s Volendam, which can cater for up to 1450 guests. I quickly notice that the grab’n’go treats are behind glass in the Lido Market dining room, where there’s an abundance of big-smiling waiting staff ready to serve me.

Only pre-plated desserts and pre-made and wrapped sandwiches can be retrieved from the general buffet area. All other meals are carried out to guests.

There are only a few areas where passengers can treat themselves, including the poolside taco servery, while in the bars, nuts are delivered in mini-carafes and have to be poured out to be consumed.

The Volendam’s hotel director Craig Oates says the reduction in self-service has been gradual and is purely to enhance the guest experience and not related to concerns over passenger hygiene.

“I joined 14 years ago and a lot of it was self-service but it’s slowly transitioned. It has not been an overnight decision to restrict self-service,” Mr Oates told AAP.

“The reason we have people making salads is, rather than people helping themselves and getting mixed up with the dressings, we wanted to add something to the guest experience.”