Norwalk virus shedding after experimental human infection

Vero Cells as a Mammalian Cell Substrate for Human Norovirus

Human norovirus (HuNoV) is a principal cause of acute gastroenteritis worldwide, particularly in developing countries. Its global prevalence is underscored by more serious morbidity and some mortality in the young (<5 years) and the elderly. To date, there are no licensed vaccines or approved therapeutics for HuNoV, mostly because there are limited cell culture systems and small animal models available. Recently described cell culture systems are not ideal substrates for HuNoV vaccine development because they are not clonal or only support a single strain. In this study, we show Vero cell-based replication of two pandemic GII.4 HuNoV strains and one GII.3 strain and confirm exosome-mediated HuNoV infection in Vero cells. Lastly, we show that trypsin addition to virus cultures or disruption of Vero cell host genes can modestly increase HuNoV replication. These data provide support for Vero cells as a cell culture model for HuNoV.

Norovirus infections and knowledge, attitudes and practices in food safety among food handlers in an informal urban settlement, Kenya 2017

Introduction

A leading cause of acute gastroenteritis, norovirus can be transmitted by infected food handlers but norovirus outbreaks are not routinely investigated in Kenya. We estimated norovirus prevalence and associated factors among food handlers in an informal urban settlement in Nairobi, Kenya.

Methods

We conducted a cross-sectional survey among food handlers using pretested questionnaires and collected stool specimens from food handlers which were analyzed for norovirus by conventional PCR. We observed practices that allow norovirus transmission and surveyed respondents on knowledge, attitudes, and practices in food safety. We calculated odd ratios (OR) with 95% confidence intervals (CI) to identify factors associated with norovirus infection. Variables with p < 0.05 were included in multivariate logistic regression analysis to calculate adjusted OR and 95% CI.

Results

Of samples from 283 respondents, 43 (15.2%) tested positive for norovirus. Factors associated with norovirus detection were: reporting diarrhea and vomiting within the previous month (AOR = 5.7, 95% CI = 1.2–27.4), not knowing aerosols from infected persons can contaminate food (AOR = 6.5, 95% CI = 1.1–37.5), not knowing that a dirty chopping board can contaminate food (AOR = 26.1, 95% CI = 1.6–416.7), observing respondents touching food bare-handed (AOR = 3.7, 95% CI = 1.5–11.1), and working in premises without hand washing services (AOR = 20, 95% CI = 3.4–100.0).

Conclusion

The norovirus infection was prevalent amongst food handlers and factors associated with infection were based on knowledge and practices of food hygiene. We recommend increased hygiene training and introduce more routine inclusion of norovirus testing in outbreaks in Kenya.

Molecular detection and characterisation of sapoviruses and noroviruses in outpatient children with diarrhoea in Northwest Ethiopia

Childhood morbidity and mortality of diarrhoeal diseases are high, particularly in low-income countries and noroviruses and sapoviruses are among the most frequent causes worldwide. Their epidemiology and diversity remain not well studied in many African countries. To assess the positivity rate and the diversity of sapoviruses and noroviruses in Northwest Ethiopia, during November 2015 and April 2016, a total of 450 faecal samples were collected from outpatient children aged &lt;5 years who presented with diarrhoea. Samples were screened for noroviruses and sapoviruses by real-time RT-PCR. Partial VP1 genes were sequenced, genotyped and phylogenetically analysed. Norovirus and sapovirus stool positivity rate was 13.3% and 10.0%, respectively. Noroviruses included GII.4 (35%), GII.6 (20%), GII.17 (13.3%), GII.10 (10%), GII.2 (6.7%), GII.16 (5%), GII.7 (3.3%), GII.9, GII.13, GII.20 and GI.3 (1.7% each) strains. For sapoviruses, GI.1, GII.1 (20.0% each), GII.6 (13.3%), GI.2 (8.9%), GII.2 (11.1%), GV.1 (8.9%), GIV.1 (6.7%), GI.3 and GII.4 (2.2% each) genotypes were detected. This study demonstrates a high genetic diversity of noroviruses and sapoviruses in Northwest Ethiopia. The positivity rate in stool samples from young children with diarrhoea was high for both caliciviruses. Continued monitoring is recommended to identify trends in genetic diversity and seasonal variations.

Environmental and Adaptive Changes Necessitate a Paradigm Shift for Indicators of Fecal Contamination

Changes in the occurrence, distribution, and seasonal variation of waterborne pathogens due to global climate change may increase the risk of human exposure to these microorganisms, thus heightening the need for more reliable surveillance systems. Routine monitoring of drinking water supplies and recreational waters is performed using fecal indicator microorganisms, such as Escherichia coli , Enterococcus spp., and coliphages. However, the presence and numbers of these indicators, especially E. coli and Enterococcus spp., do not correlate well with those of other pathogens, especially enteric viruses, which are a major cause of waterborne outbreaks associated with contaminated water and food, and recreational use of lakes, ponds, rivers, and estuarine waters. For that reason, there is a growing need for a surveillance system that can detect and quantify viral pathogens directly in water sources to reduce transmission of pathogens associated with fecal transmission. In this review, we present an updated overview of relevant waterborne enteric viruses that we believe should be more commonly screened to better evaluate water quality and to determine the safety of water use and reuse and of epidemiological data on viral outbreaks. We also discuss current methodologies that are available to detect and quantify these viruses in water resources. Finally, we highlight challenges associated with virus monitoring. The information presented in this review is intended to aid in the assessment of human health risks due to contact with water sources, especially since current environmental and adaptive changes may be creating the need for a paradigm shift for indicators of fecal contamination.

Microbiological contamination of conventional and reclaimed irrigation water: Evaluation and management measures

The wide diversity of irrigation water sources (i.e., drinking water, groundwater, reservoir water, river water) includes reclaimed water as a requested measure for increasing water availability, but it is also a challenge as pathogen exposure may increase. This study evaluates the level of microbial contamination in different irrigation waters to improve the knowledge and analyses management measures for safety irrigation. Over a one-year period, the occurrence of a set of viruses, bacteria and protozoa, was quantified and the performance of a wetland system, producing reclaimed water intended for irrigation, was characterized. Human fecal pollution (HAdV) was found in most of the irrigation water types analysed. Hepatitis E virus (HEV), an emerging zoonotic pathogen, was present in groundwater where porcine contamination was identified (PAdV). The skin-carcinoma associated Merkel cell polyomavirus (MCPyV), was found occasionally in river water. Noroviruses were detected, as expected, in winter, in river water and reclaimed water. Groundwater, river water and reservoir water also harboured potential bacterial pathogens, like Helicobacter pylori, Legionella spp. and Aeromonas spp. that could be internalized and viable inside amoebas like Acanthamoeba castellanii, which was also detected. Neither Giardia cysts, nor any Cryptosporidium oocysts were detected. The wetland system removed 3 Log10 of viruses and 5 Log10 of bacteria, which resembled the river water quality. Irrigation waters were prone to variable contamination levels and according to the European guidance documents, the E. coli (EC) levels were not always acceptable. Sporadic detection of viral pathogens as NoV GII and HAdV was identified in water samples presenting lower EC than the established limit (100MNP/100 mL). When dealing with reclaimed water as a source of irrigation the analysis of some viral parameters, like HAdV during the peak irrigation period (summer and spring) or NoV during the coldest months, could complement existing water management tools based on bacterial indicators.

Quantitative PCR Detection of Enteric Viruses in Wastewater and Environmental Water Sources by the Lisbon Municipality: A Case Study

Current regulations and legislation require critical revision to determine safety for alternative water sources and water reuse as part of the solution to global water crisis. In order to fulfill those demands, Lisbon municipality decided to start water reuse as part of a sustainable hydric resources management, and there was a need to confirm safety and safeguard for public health for its use in this context. For this purpose, a study was designed that included a total of 88 samples collected from drinking, superficial, underground water, and wastewater at three different treatment stages. Quantitative Polimerase Chain Reaction (PCR) detection (qPCR) of enteric viruses Norovirus (NoV) genogroups I (GI) and II (GII) and Hepatitis A (HepA) was performed, and also FIB (E. coli, enterococci and fecal coliforms) concentrations were assessed. HepA virus was only detected in one untreated influent sample, whereas NoV GI/ NoV GI were detected in untreated wastewater (100/100%), secondary treated effluent (47/73%), and tertiary treated effluent (33/20%). Our study proposes that NoV GI and GII should be further studied to provide the support that they may be suitable indicators for water quality monitoring targeting wastewater treatment efficiency, regardless of the level of treatment.

Norovirus Seroprevalence among Adults in the United States: Analysis of NHANES Serum Specimens from 1999-2000 and 2003-2004

Norovirus is the most common cause of epidemic and endemic acute gastroenteritis. However, national estimates of the infection burden are challenging. This study used a nationally representative serum bank to estimate the seroprevalence to five norovirus genotypes including three GII variants: GI.1 Norwalk, GI.4, GII.3, GII.4 US95/96, GII.4 Farmington Hills, GII.4 New Orleans, and GIV.1 in the USA population (aged 16 to 49 years). Changes in seroprevalence to the three norovirus GII.4 variants between 1999 and 2000, as well as 2003 and 2004, were measured to examine the role of population immunity in the emergence of pandemic GII.4 noroviruses. The overall population-adjusted seroprevalence to any norovirus was 90.0% (1999 to 2000) and 95.9% (2003 to 2004). Seroprevalence was highest to GI.1 Norwalk, GII.3, and the three GII.4 noroviruses. Seroprevalence to GII.4 Farmington Hills increased significantly between the 1999 and 2000, as well as the 2003 and 2004, study cycles, consistent with the emergence of this pandemic strain. Seroprevalence to GII.4 New Orleans also increased over time, but to a lesser degree. Antibodies against the GIV.1 norovirus were consistently detected (population-adjusted seroprevalence 19.1% to 25.9%), with rates increasing with age. This study confirms the high burden of norovirus infection in US adults, with most adults having multiple norovirus infections over their lifetime.

Efficient management of a norovirus outbreak causing gastroenteritis in two hotels in Spain, 2014

OBJECTIVES

To determine the aetiological agent causing a gastroenteritis outbreak in two hotels in Majorca (Spain) on August and September 2014.

METHODS

An epidemiological study was carried out. Environmental and stool samples were analyzed for different pathogens, including norovirus.

RESULTS

Epidemiological analysis detected 79 cases among the tourists hosted in the affected hotels over the period 18th August to 3rd September. They included 52 (attack rate: 6.4%) and 27 (attack rate: 3.0%) cases in hotel A and B, respectively. Seven of the staff members were also affected. Microbiological analyses detected genotype 2 norovirus in patient's stool samples, in rooms and in common areas' surfaces. The specific control plan rapidly implemented at the beginning of the outbreak, and further adapted for norovirus elimination, allowed to control the outbreak.

CONCLUSIONS

Our study demonstrates that the outbreak was caused by genotype 2 norovirus, and reflects the importance of a rapid analysis and response for its control.

Emergence of norovirus strains: A tale of two genes

Noroviruses are a very diverse group of viruses that infect different mammalian species. In humans, norovirus is a major cause of acute gastroenteritis. Multiple norovirus infections can occur in a lifetime as the result of limited duration of acquired immunity and cross-protection among different strains. A combination of advances in sequencing methods and improvements on surveillance has provided new insights into norovirus diversification and emergence. The generation of diverse norovirus strains has been associated with (1) point mutations on two different genes: ORF1, encoding the non-structural proteins, and ORF2, encoding the major capsid protein (VP1); and (2) recombination events that create chimeric viruses. While both mechanisms are exploited by all norovirus strains, individual genotypes utilize each mechanism differently to emerge and persist in the human population. GII.4 noroviruses (the most prevalent genotype in humans) present an accumulation of amino acid mutations on VP1 resulting in the chronological emergence of new variants. In contrast, non-GII.4 noroviruses present co-circulation of different variants over long periods with limited changes on their VP1. Notably, genetic diversity of non-GII.4 noroviruses is mostly related to the high number of recombinant strains detected in humans. While it is difficult to determine the precise mechanism of emergence of epidemic noroviruses, observations point to multiple factors that include host-virus interactions and changes on two regions of the genome (ORF1 and ORF2). Larger datasets of viral genomes are needed to facilitate comparison of epidemic strains and those circulating at low levels in the population. This will provide a better understanding of the mechanism of norovirus emergence and persistence.

7 Log Virus Removal in a Simple Functionalized Sand Filter

Viral contamination of drinking water due to fecal contamination is difficult to detect and treat effectively, leading to frequent outbreaks worldwide. The purpose of this paper is to report on the molecular mechanism for unprecedented high virus removal from a practical sand filter. Sand filters functionalized using a water extract of Moringa oleifera (MO) seeds, functionalized sand (f-sand) filters, achieved a ∼7 log₁₀ virus removal. These tests were conducted with MS2 bacteriophage, a recognized surrogate for pathogenic norovirus and rotavirus. We studied the molecular mechanism of this high removal since it can have important implications for sand filtration, the most common water treatment technology worldwide. Our data reveal that the virus removal activity of f-sand is due to the presence of a chitin-binding protein, M. oleifera chitin-binding protein (MoCBP) on f-sand. Standard column experiments were supported by proteomic analysis and molecular docking simulations. Our simulations show that MoCBP binds preferentially to MS2 capsid proteins demonstrating that specific molecular interactions are responsible for enhanced virus removal. In addition, we simplified the process of making f-sand and evinced how it could be regenerated using saline water. At present, no definitive solution exists for the challenge of treating fecally contaminated drinking and irrigation water for viruses without using technologies that demand high energy or chemical consumption. We propose functionalized sand (f-sand) filters as a highly effective, energy-efficient, and practical technology for virus removal applicable to both developing and developed countries.

Norovirus encounters in the gut: multifaceted interactions and disease outcomes

Noroviruses are major causes of gastroenteritis, with epidemic outbreaks occurring frequently. They are an important global health concern, especially for pediatric and immunocompromised populations, and are challenging pathogens to target immunologically due to their rapid rates of genetic and antigenic evolution and failure to stimulate durable protective immunity. In this Review, we summarize our current understanding of norovirus pathogenesis, noting the prominent role of murine norovirus as a small animal model for norovirus research. We highlight intriguing data supporting the possible involvement of norovirus in sequelae including irritable bowel syndrome and inflammatory bowel diseases, and describe the innate and adaptive immune mechanisms involved in control of both human and murine norovirus infection. Furthermore, we discuss the potential implications of recent discoveries regarding norovirus interactions with the gut microbiota, and briefly detail current understanding of noroviral evolution and its influence on viral pathogenesis. Our mechanistic understanding of norovirus pathogenesis continues to improve with increasing availability of powerful model systems, which will ultimately facilitate development of effective preventive and therapeutic approaches for this pathogen.

Effect of natural ageing and heat treatments on GII.4 norovirus binding to Histo-Blood Group Antigens

Human noroviruses (HuNoVs) are the leading cause of viral foodborne outbreaks worldwide. To date, no available methods can be routinely used to detect infectious HuNoVs in foodstuffs. HuNoVs recognize Histo-Blood Group Antigens (HBGAs) through the binding pocket (BP) of capsid protein VP1, which promotes infection in the host cell. In this context, the suitability of human HBGA-binding assays to evaluate the BP integrity of HuNoVs was studied on GII.4 virus-like particles (VLPs) and GII.4 HuNoVs during natural ageing at 20 °C and heat treatments. Our results demonstrate that this approach may reduce the over-estimation of potential infectious HuNoVs resulting from solely using the genome detection, even though some limitations have been identified. The specificity of HBGA-binding to the BP is clearly dependent on the HGBA type (as previously evidenced) and the ionic strength of the media without disturbing such interactions. This study also provides new arguments regarding the ability of VLPs to mimic HuNoV behavior during inactivation treatments. The BP stability of VLPs was at least 4.3 fold lower than that of HuNoVs at 20 °C, whereas capsids of both particles were disrupted at 72 °C. Thus, VLPs are relevant surrogates of HuNoVs for inactivation treatments inducing significant changes in the capsid structure.

Microbial Contamination of Fresh Produce: What, Where, and How?

Promotion of healthier lifestyles has led to an increase in consumption of fresh produce. Such foodstuffs may expose consumers to increased risk of foodborne disease, as often they are not subjected to processing steps to ensure effective removal or inactivation of pathogenic microorganisms before consumption. Consequently, reports of ready-to-eat fruit and vegetable related disease outbreak occurrences have increased substantially in recent years, and information regarding these events is often not readily available. Identifying the nature and source of microbial contamination of these foodstuffs is critical for developing appropriate mitigation measures to be implemented by food producers. This review aimed to identify the foodstuffs most susceptible to microbial contamination and the microorganisms responsible for disease outbreaks from information available in peer-reviewed scientific publications. A total of 571 outbreaks were identified from 1980 to 2016, accounting for 72,855 infections and 173 deaths. Contaminated leafy green vegetables were responsible for 51.7% of reported outbreaks. Contaminated soft fruits caused 27.8% of infections. Pathogenic strains of Escherichia coli and Salmonella, norovirus, and hepatitis A accounted for the majority of cases. Large outbreaks resulted in particular biases such as the observation that contaminated sprouted plants caused 31.8% of deaths. Where known, contamination mainly occurred via contaminated seeds, water, and contaminated food handlers. There is a critical need for standardized datasets regarding all aspects of disease outbreaks, including how foodstuffs are contaminated with pathogenic microorganisms. Providing food business operators with this knowledge will allow them to implement better strategies to improve safety and quality of fresh produce.

Evaluation of a laboratory-developed test for simultaneous detection of norovirus and rotavirus by real-time RT-PCR on the Panther Fusion® system

The Hologic Panther Fusion® Open Access™ functionality allows implementation of laboratory-developed tests (LDTs), with fully automated sample extraction, real-time PCR, and result interpretation. We report the development and validation of a multiplex LDT for norovirus G1, norovirus G2, and rotavirus from stool samples on this system. The LDT was optimized for primer and probe sequences, salt concentration, and PCR annealing temperature. Reproducibility of the PCR and extraction process was assessed. Performance of the multiplex LDT assay was evaluated with external quality assessment (EQA) samples and compared to a commercial multiplex assay (Allplex™ GI-Virus Assay, Seegene) in clinical samples. Salt concentrations and annealing/extension temperature were optimized to 4 mM MgCl₂, 70 mM KCl, 20 mM Tris, and 60 °C, respectively. The user-prepared part of the LDT PCR mix (containing salts, probes, and primers) was stable for ≥ 11 days onboard the instrument. We observed reproducible results of PCR and the extraction process. The LDT had a sensitivity comparable to or greater than the commercial Allplex™ assay and showed excellent linearity. Forty-five EQA samples yielded the expected result with the LDT. There was 100% concordance between LDT and Allplex™ results in 160 clinical samples. Results from the suspension and direct swab stool sample preparation methods were highly concordant in the LDT. We report the successful development and validation of a multiplex PCR LDT for detection of norovirus G1, norovirus G2, and rotavirus from stool samples on the Panther Fusion® system.

Detection of Hepatitis A Virus and Other Enteric Viruses in Shellfish Collected in the Gulf of Naples, Italy

To assess the quality of shellfish harvest areas, bivalve mollusk samples from three coastal areas of the Campania region in Southwest Italy were evaluated for viruses over a three-year period (2015-2017). Screening of 289 samples from shellfish farms and other locations by qPCR and RT-qPCR identified hepatitis A virus (HAV; 8.9%), norovirus GI (NoVGI; 10.8%) and GII (NoVGII; 39.7%), rotavirus (RV; 9.0%), astrovirus (AsV; 20.8%), sapovirus (SaV; 18.8%), aichivirus-1 (AiV-1; 5.6%), and adenovirus (AdV, 5.6%). Hepatitis E virus (HEV) was never detected. Sequence analysis identified HAV as genotype IA and AdV as type 41. This study demonstrates the presence of different enteric viruses within bivalve mollusks, highlighting the limitations of the current EU classification system for shellfish growing waters.

Norovirus shedding among symptomatic and asymptomatic employees in outbreak settings in Shanghai, China

Background

Norovirus (NoV) is recognized as a leading cause of acute gastroenteritis (AGE) outbreaks in settings globally. Studies have shown that employees played an important role in the transmission mode during some NoV outbreaks. This study aimed to investigate the prevalence of NoV infection and duration of NoV shedding among employees during NoV outbreaks, as well as factors affecting shedding duration.

Methods

Specimens and epidemiological data were collected from employees who were suspected of being involved in the transmission or with AGE symptoms during NoV outbreaks in Xuhui District, Shanghai, from 2015 to 2017. Specimens were detected using real-time RT-PCR to determine whether or not employees had become infected with NoV. Specimens were collected every 3–7 days from NoV-infected employees until specimens became negative for NoV.

Results

A total of 421 employees were sampled from 49 NoV outbreaks, and nearly 90% of them (377/421) were asymptomatic. Symptomatic employees showed significantly higher prevalence of NoV infection than asymptomatic ones (70.5% vs. 17.0%, P < 0.01). The average duration of NoV shedding was 6.9 days (95% confidence interval: 6.1–7.7 days) among 88 NoV-infected individuals, and was significantly longer in symptomatic individuals than in asymptomatic ones (9.8 days vs. 5.6 days, P < 0.01). In Cox proportional-hazards model, after adjusting age and gender, symptoms was the only factor associated with duration of NoV shedding.

Conclusions

Compared with asymptomatic employees, symptomatic employees had higher prevalence of NoV infection and longer durations of NoV shedding. Since NoV shedding duration among NoV-infected employees tends to be longer than their isolation time during outbreaks, reinforcement of hygiene practices among these employees is especially necessary to reduce the risk of virus secondary transmissions after their return to work.

Cockles and mussels, alive, alive, oh-The role of bivalve molluscs as transmission vehicles for human norovirus infections

Human noroviruses are recognized as the leading worldwide cause of sporadic and epidemic viral gastroenteritis, causing morbidity and mortality in impoverished developing countries and engendering enormous economic losses in developed countries. Transmitted faecal-orally, either via person-to-person contact, or by consumption of contaminated foods or water, norovirus outbreaks are often reported in institutional settings or in the context of communal dining. Bivalve molluscs, which accumulate noroviruses via filter feeding and are often eaten raw or insufficiently cooked, are a common food vehicle implicated in gastroenteritis outbreaks. The involvement of bivalve molluscs in norovirus outbreaks and epidemiology over the past two decades are reviewed. The authors describe how their physiology of filter feeding can render them concentrated vehicles of norovirus contamination in polluted environments and how high viral loads persist in molluscs even after application of depuration practices and typical food preparation steps. The global prevalence of noroviruses in bivalve molluscs as detected by different monitoring efforts is determined and the various methods currently utilized for norovirus extraction and detection from bivalve matrices described. An overview of gastroenteritis outbreaks affirmatively associated with norovirus-contaminated bivalve molluscs as reported in the past 18 years is also provided. Strategies for risk reduction in shellfish contamination and subsequent human infection are discussed.

In Vitro Replication of Human Norovirus

Human norovirus (HuNoV) infection is a major cause of gastroenteritis all over the world. Despite this, these non-enveloped RNA viruses are poorly characterized due to the lack of robust and widely available HuNoV culture systems. The two published systems (B cell line and stem cell-derived enteroids) support replication of HuNoVs but the levels of replication are not sufficient for the generation of highly purified virus stocks or the development of culture-based quantification assays. Therefore, improvement of HuNoV in vitro replication is still needed. Murine norovirus and other caliciviruses have provided insights into norovirus replication that paved the way for the development of the current HuNoV culture systems and may also aid in the improvement of these systems. This review will highlight ways in which previous research guided and impacted the development of HuNoV culture systems and discuss ways in which more recent discoveries might be utilized to improve the quality of the HuNoV in vitro replication.

A Secreted Viral Nonstructural Protein Determines Intestinal Norovirus Pathogenesis

Murine norovirus (MNoV) infects a low percentage of enteric tuft cells and can persist in these cells for months following acute infection. Both tuft-cell tropism and resistance to interferon-λ (IFN-λ)-mediated clearance during persistent infection requires the viral nonstructural protein 1/2 (NS1/2). We show that processing of NS1/2 yields NS1, an unconventionally secreted viral protein that is central for IFN-λ resistance. MNoV infection globally suppresses intestinal IFN-λ responses, which is attributable to secreted NS1. MNoV NS1 secretion is triggered by caspase-3 cleavage of NS1/2, and a secreted form of human NoV NS1 is also observed. NS1 secretion is essential for intestinal infection and resistance to IFN-λ in vivo. NS1 vaccination alone protects against MNoV challenge, despite the lack of induction of neutralizing anti-capsid antibodies previously shown to confer protection. Thus, despite infecting a low number of tuft cells, NS1 secretion allows MNoV to globally suppress IFN responses and promote persistence.

Norovirus Outbreak in a Kindergarten: Human to Human Transmission among Children

An outbreak of acute gastroenteritis was reported from a kindergarten on January 5, 2018 and investigation was conducted. A case was defined as a kindergartener presented with vomiting or diarrhea twice a day between January 1 and January 5, 2018. All kindergarteners were interviewed to identify the factor associated with case development. Fifteen (31.3%) children of a total of 48 were identified as cases, and four were confirmed to be Group II, Norovirus positive. In our study, based on the pattern of epidemic curve and different attack rate by classroom in a kindergarten, Norovirus was likely transmitted from human to human.

Norovirus antivirals: Where are we now?

Human noroviruses inflict a significant health burden on society and are responsible for approximately 699 million infections and over 200 000 estimated deaths worldwide each year. Yet despite significant research efforts, approved vaccines or antivirals to combat this pathogen are still lacking. Safe and effective antivirals are not available, particularly for chronically infected immunocompromised individuals, and for prophylactic applications to protect high-risk and vulnerable populations in outbreak settings. Since the discovery of human norovirus in 1972, the lack of a cell culture system has hindered biological research and antiviral studies for many years. Recent breakthroughs in culturing human norovirus have been encouraging, however, further development and optimization of these novel methodologies are required to facilitate more robust replication levels, that will enable reliable serological and replication studies, as well as advances in antiviral development. In the last few years, considerable progress has been made toward the development of norovirus antivirals, inviting an updated review. This review focuses on potential therapeutics that have been reported since 2010, which were examined across at least two model systems used for studying human norovirus or its enzymes. In addition, we have placed emphasis on antiviral compounds with a defined chemical structure. We include a comprehensive outline of direct-acting antivirals and offer a discussion of host-modulating compounds, a rapidly expanding and promising area of antiviral research.

Probabilistic modeling for an integrated temporary acquired immunity with norovirus epidemiological data

Integration of acquired immunity into microbial risk assessment for illness incidence is of no doubt essential for the study of susceptibility to illness. In this study, a probabilistic model was set up as dose response for infection and a mathematical derivation was carried out by integrating immunity to obtain probability of illness models. Temporary acquire immunity from epidemiology studies which includes six different Norovirus transmission scenarios such as symptomatic individuals infectious, pre- and post-symptomatic infectiousness (low and high), innate genetic resistance, genogroup 2 type 4 and those with no immune boosting by asymptomatic infection were evaluated. Simulated results on illness inflation factor as a function of dose and exposure indicated that high frequency exposures had immense immunity build up even at high dose levels; hence minimized the probability of illness. Using Norovirus transmission dynamics data, results showed, and immunity included models had a reduction of 2-6 logs of magnitude difference in disease burden for both population and individual probable illness incidence. Additionally, the magnitude order of illness for each dose response remained largely the same for all transmission scenarios; symptomatic infectiousness and no immune boosting after asymptomatic infectiousness also remained the same throughout. With integration of epidemiological data on acquired immunity into the risk assessment, more realistic results were achieved signifying an overestimation of probable risk of illness when epidemiological immunity data are not included. This finding supported the call for rigorous integration of temporary acquired immunity in dose-response in all microbial risk assessments.

Nlrp3 inflammasome activation and Gasdermin D-driven pyroptosis are immunopathogenic upon gastrointestinal norovirus infection

Norovirus infection is the leading cause of food-borne gastroenteritis worldwide, being responsible for over 200,000 deaths annually. Studies with murine norovirus (MNV) showed that protective STAT1 signaling controls viral replication and pathogenesis, but the immune mechanisms that noroviruses exploit to induce pathology are elusive. Here, we show that gastrointestinal MNV infection leads to widespread IL-1β maturation in MNV-susceptible STAT1-deficient mice. MNV activates the canonical Nlrp3 inflammasome in macrophages, leading to maturation of IL-1β and to Gasdermin D (GSDMD)-dependent pyroptosis. STAT1-deficient macrophages displayed increased MAVS-mediated expression of pro-IL-1β, facilitating elevated Nlrp3-dependent release of mature IL-1β upon MNV infection. Accordingly, MNV-infected Stat1^-/- mice showed Nlrp3-dependent maturation of IL-1β as well as Nlrp3-dependent pyroptosis as assessed by in vivo cleavage of GSDMD to its active N-terminal fragment. While MNV-induced diarrheic responses were not affected, Stat1^-/- mice additionally lacking either Nlrp3 or GSDMD displayed lower levels of the fecal inflammatory marker Lipocalin-2 as well as delayed lethality after gastrointestinal MNV infection. Together, these results uncover new insights into the mechanisms of norovirus-induced inflammation and cell death, thereby revealing Nlrp3 inflammasome activation and ensuing GSDMD-driven pyroptosis as contributors to MNV-induced immunopathology in susceptible STAT1-deficient mice.

Gastrointestinal norovirus infections form a serious socio-economic worldwide problem, with about 684 million cases annually worldwide and mortality occurring both in underdeveloped countries and in immunocompromised patients. Despite the urgent global need, no specific treatments are available for norovirus induced gastroenteritis, partly because innate immune responses upon gastrointestinal norovirus infection are largely unresolved. Using the murine norovirus (MNV) model we showed that MNV infection in macrophages leads to a lytic form of cell death termed pyroptosis as well as to the maturation and release of the pro-inflammatory cytokine IL-1β. Maturation of IL-1β was observed also in vivo, after gastrointestinal infection of MNV-susceptible Stat1 knockout mice. We found that these innate immune responses upon MNV infection crucially depended on activation of the Nlrp3 inflammasome leading to Gasdermin D-driven pyroptosis, and inactivating this signaling pathway delayed lethality of MNV-susceptible STAT1 knockout mice after gastrointestinal MNV infection. We thus identified Nlrp3 inflammasome activation and ensuing pyroptosis as a signaling pathway contributing to norovirus-induced immunopathology. Taken together, this study resulted in a more detailed understanding of MNV-induced inflammatory and cell death pathways and provided insights into how gastrointestinal viruses induce immunopathology.

Epidemiology of Norovirus Outbreaks Reported to the Public Health Emergency Event Surveillance System, China, 2014⁻2017

We conducted a retrospective analysis of norovirus outbreaks reported to the National Public Health Emergency Event Surveillance System (PHEESS) in China from January 1, 2014 to December 31, 2017. We reviewed all acute gastroenteritis outbreaks (n = 692) submitted to PHEESS to identify the frequency, seasonality, geographic distribution, setting, and transmission mode of outbreaks due to norovirus. A total of 616 norovirus outbreaks resulting in 30,848 cases were reported. Among these outbreaks, 571 (93%) occurred in school settings including 239 (39%) in primary schools, 136 (22%) in childcare facilities, and 121 (20%) in secondary schools. The majority of outbreaks (63%) were due to person-to-person transmission, followed by multiple modes of transmission (11%), foodborne (5%) and waterborne (3%) transmission. These findings highlight the importance of improving hand hygiene and environmental disinfection in high-risk settings. Developing a standard and quantitative outbreak reporting structure could improve the usefulness of PHEESS for monitoring norovirus outbreaks.

Final Consumer Options to Control and Prevent Foodborne Norovirus Infections

Norovirus (NoV) causes about one-fifth of all cases of foodborne diseases and is a foremost cause of domestically acquired foodborne acute gastroenteritis and outbreaks. NoV infections are often associated with the consumption of contaminated fresh and ready-to-eat produce, fresh and frozen berries, raw/undercooked bivalve mollusks and products which become contaminated during handling. Despite many industrial efforts to control and prevent NoV contamination of foods, the prevalence of NoV in high-risk foodstuffs at retail is still significant. Although certain consumer behaviors may even increase the risk of virus transmission, interventions aiming at changing/implementing consumer habits may be considered as opportunities for risk mitigation. This review aims at providing an update on the progress made in characterizing the effect that consumer habits, which are most critical to prevent NoV transmission (food choice and hygiene, disinfection and cooking during food preparation), may have on reducing the risk of NoV infection. A better understanding of the options for NoV control and prevention may be translated into innovative educational, social or even technological tools targeting consumers with the objective of mitigating the risk of NoV transmission.

Wastewater-Based Epidemiology for Early Detection of Viral Outbreaks

The immense global burden of infectious disease outbreaks and the need to establish prediction and prevention systems have been recognized by the World Health Organization (WHO), the National Institutes of Health (NIH), the United States Agency of International Development (USAID), the Bill and Melinda Gates Foundation, and the international scientific community. Despite multiple efforts, this infectious burden is still increasing. For example, it has been reported that between 1.5 and 12 million people die each year from waterborne diseases and diarrheal diseases are listed within the top 15 leading causes of death worldwide. Rapid population growth, climate change, natural disasters, immigration, globalization, and the corresponding sanitation and waste management challenges are expected to intensify the problem in the years to come.

Active Surveillance for Norovirus in a US Veterans Affairs Patient Population, Houston, Texas, 2015-2016

Background

Norovirus is a leading cause of acute gastroenteritis (AGE); however, few data exist on endemic norovirus disease burden among adults. Candidate norovirus vaccines are currently in development for all ages, and robust estimates of norovirus incidence among adults are needed to provide baseline data.

Methods

We conducted active surveillance for AGE among inpatients at a Veterans Affairs (VA) hospital in Houston, Texas. Patients with AGE (≥3 loose stools, ≥2 vomiting episodes, or ≥1 episode of both loose stool and vomiting, within 24 hours) within 10 days of enrollment and non-AGE control patients were enrolled. Demographic data and clinical characteristics were collected. Stool samples were tested using the FilmArray gastrointestinal panel; virus-positives were confirmed by real-time reverse transcription polymerase chain reaction and genotyped by sequencing.

Results

From November 2, 2015 through November 30, 2016, 147 case patients and 19 control patients were enrolled and provided a stool specimen. Among case patients, 139 (95%) were male and 70 (48%) were aged ≥65 years. Norovirus was the leading viral pathogen detected (in 16 of 20 virus-positive case patients) and accounted for 11% of all AGE cases. No viral pathogens were detected among control patients. Incidence of norovirus-associated hospitalization was 20.3 cases/100 000 person-years and was similar among those aged <65 and ≥65 years.

Conclusions

This active surveillance platform employed screening and enrollment of hospitalized VA patients meeting a standardized AGE case definition, as well as non-AGE control patients. Data from this study highlight the burden of norovirus in a VA inpatient population and will be useful in policy considerations of a norovirus vaccine.

Specific Interactions between Human Norovirus and Environmental Matrices: Effects on the Virus Ecology

Human norovirus is the major cause of non-bacterial epidemic gastroenteritis. Human norovirus binds to environmental solids via specific and non-specific interactions, and several specific receptors for human norovirus have been reported. Among them, histo-blood group antigens (HBGA) are the most studied specific receptor. Studies have identified the presence of HBGA-like substances in the extracellular polymeric substances (EPS) and lipopolysaccharides (LPS) of human enteric bacteria present in aquatic environments, gastrointestinal cells, gills, and palps of shellfish, and cell walls, leaves, and veins of lettuce. These HBGA-like substances also interact with human norovirus in a genotype-dependent manner. Specific interactions between human norovirus and environmental matrices can affect norovirus removal, infectivity, inactivation, persistence, and circulation. This review summarizes the current knowledge and future directions related to the specific interactions between human norovirus and HBGA-like substances in environmental matrices and their possible effects on the fate and circulation of human norovirus.

Human Norovirus: Experimental Models of Infection

Human noroviruses (HuNoVs) are a leading cause of acute gastroenteritis worldwide. HuNoV infections lead to substantial societal and economic burdens. There are currently no licensed vaccines or therapeutics for the prevention or treatment of HuNoVs. A lack of well-characterized in vitro and in vivo infection models has limited the development of HuNoV countermeasures. Experimental infection of human volunteers and the use of related viruses such as murine NoV have provided helpful insights into HuNoV biology and vaccine and therapeutic development. There remains a need for robust animal models and reverse genetic systems to further HuNoV research. This review summarizes available HuNoV animal models and reverse genetic systems, while providing insight into their usefulness for vaccine and therapeutic development.

Transmissibility of Norovirus in Urban Versus Rural Households in a Large Community Outbreak in China

BACKGROUND

Norovirus is a leading cause of outbreaks of acute infectious gastroenteritis worldwide, yet its transmissibility within households and associated risk factors remain unknown in developing countries.

METHODS

Household, demographic, and clinical data were collected from a semi-urban area in south China where an outbreak occurred in the winter of 2014. Using a Bayesian modeling framework, we assessed the transmissibility and potential risk modifiers in both urban and rural households.

RESULTS

In urban apartment buildings, the secondary attack rates were 84% (95% credible interval [CI] = 60%, 96%) among households of size two and 29% (95% CI = 9.6%, 53%) in larger households. In the rural village, secondary attack rate estimates were lower than the urban setting, 13% (0.51%, 54%) for households of size two and 7.3% (0.38%, 27%) for larger households. Males were 31% (95% CI = 3%, 50%) less susceptible to the disease than female. Water disinfection with chlorine was estimated to reduce environmental risk of infection by 60% (95% CI = 26%, 82%), and case isolation was estimated to reduce person-to-person transmission by 65% (95% CI = 15%, 93%). Nausea and vomiting were not associated with household transmission.

CONCLUSIONS

Norovirus is highly contagious within households, in particular in small households in urban communities. Our results suggest that water disinfection and case isolation are associated with reduction of outbreaks in resource-limited communities.

Vomiting symptom of acute gastroenteritis estimated from epidemiological data can help predict river contamination by human pathogenic enteric viruses

Contamination of fresh water bodies by human enteric viruses from wastewater discharge is a well-established phenomenon. Here we propose a model of viral contamination of rivers based on acute gastroenteritis epidemiology and assess how well it can simulate in situ experimental monitoring. Noroviruses, rotaviruses, enteroviruses, adenoviruses and hepatitis A viruses were quantified by molecular methods after water concentration. Water flows were obtained from the Hydro databank and wastewater treatment plant (WWTP) data. Acute gastroenteritis cases based on medical prescriptions were recorded by the French public health agency. We estimated the total number of daily viral acute gastroenteritis cases and modeled virus shedding and fate in WWTPs and rivers. Simulated virus concentrations were compared to the weighted sum of measured concentrations. Seasonal variations in viral acute gastroenteritis were predicted from vomiting occurrence. All viruses except hepatitis A virus were widely detected in wastewaters and river, in concentrations reaching 10⁺⁶ genome copies·L^-1 for adenoviruses in the Artière River. We were able to predict virus load in raw wastewater and in the Artière River. Estimated weighting coefficients showed the high impact of noroviruses GII. This model can thus serve to compare water treatment, discharge and reuse scenarios.

Hydrogen peroxide vapour treatment inactivates norovirus but has limited effect on post-treatment viral RNA levels

BACKGROUND

Hydrogen peroxide vapour is used as a room disinfectant. Its activity against murine norovirus, a surrogate viability marker for human norovirus, indicates that it is also active against human norovirus.

AIM

The aim of this study is to assess how this effect on viability is reflected in measurements of RNA by quantitative PCR (qPCR).

METHODS

Faeces suspensions of two human norovirus field strains, genogroup I and II and one cultured murine norovirus strain, (genogroup V) were dried on plastic plates, and underwent hydrogen peroxide vapour treatment or were mock treated. The influence of hydrogen peroxide on RNA was measured on genogroups I, II and V by qPCRs and for the cultivable murine norovirus also for viability by cell culture. Virucidal activity on murine norovirus was measured by endpoint titrations as the 50% tissue culture infectious dose, based both on cytopathic effect and on presence of replicating intracellular minus strand RNA.

RESULTS

The mean impact on the human norovirus qPCRs was 0.4 log₁₀. The murine norovirus qPCR changed by 1.7 log₁₀ but by an alternative qPCR only by 0.4 log₁₀. These minor changes contrasted the 4.5-5.0 log₁₀ murine norovirus viability reduction after treatment measured by cytopathic effect or intracellular negative-strand RNA.

CONCLUSION

Inactivation of murine norovirus viability by hydrogen peroxide vapour was not reflected in qPCR levels. This finding might be extrapolated to the related human norovirus genogroups. We further found that cellular minus strand murine norovirus PCR was an observer-independent marker to study reduction of murine norovirus viability.

The Population-Level Impacts of Excluding Norovirus-Infected Food Workers From the Workplace: A Mathematical Modeling Study

Norovirus is the leading cause of acute gastroenteritis and foodborne disease in the United States. The Food and Drug Administration recommends that food workers infected with norovirus be excluded from the workplace while symptomatic and for 48 hours after their symptoms subside. Compliance with this recommendation is not ideal, and the population-level impacts of changes in food-worker compliance have yet to be quantified. We aimed to assess the population impacts of varying degrees of compliance with the current recommendation through the use of a compartmental model. We modeled the number and proportion of symptomatic norovirus cases averted annually in the US population (using data from 1983-2014) in specific age groups (children aged <5 years, children aged 5-17 years, adults aged 18-64 years, and adults aged ≥65 years) under various scenarios of food-worker exclusion (i.e., proportion compliant and days of postsymptomatic exclusion) in comparison with a referent scenario which assumed that 66.6¯% of norovirus-symptomatic food workers and 0% of postsymptomatic food workers were excluded from work. Overall, we estimated that 6.0 million cases of norovirus have already been avoided annually under the referent scenario and that 6.7 million (28%) more cases might be avoided through 100% compliance with the current recommendations. Substantial population-level benefits were predicted from improved compliance in exclusion of norovirus-infected food workers from the workplace-benefits that may be realized through policies or programs incentivizing self-exclusion.

Control of norovirus infection

PURPOSE OF REVIEW

The purpose of the review is to provide an update on control measures for norovirus (NoV), which is the most commonly implicated pathogen in acute gastroenteritis and outbreaks, causing major disruption in nurseries, schools, hospitals and care homes.

RECENT FINDINGS

Important developments include the discovery that virus particles, previously considered to be the infectious unit, also occur in clusters, which appear to be more virulent than individual virus particles; a working culture system using human stem-cell derived enteroids; promising results from early phase clinical trials of candidate NoV vaccines, which appear to be safe and immunogenic; chronic NoV affects patients with primary and secondary immune deficiencies. Although several treatments have been used none are supported by well designed clinical trials; infection control procedures are effective if properly implemented.

SUMMARY

NoV remains an important cause of morbidity and mortality. Although there are exciting developments on the vaccine front, the mainstay of control remains good hand hygiene, adherence to infection control procedures and limiting contamination of food, water and the wider environment. Once vaccines are available there will be important decisions to be made about how best to implement them.

Epidemiologic challenges in norovirus vaccine development

Norovirus is the leading cause of acute gastroenteritis (AGE) worldwide. In the United States norovirus is estimated to cause 19-21 million illnesses, 1.7-1.9 million outpatient visits, 56,000-71,000 hospitalizations, and 570-800 deaths annually. Through direct costs and loss of productivity, norovirus disease cost the US economy more than $5.5 billion annually. Due to the lack of available therapies to treat norovirus infections and their highly infectious nature, preventing norovirus illness through vaccination is an appealing strategy. Currently, several norovirus vaccines are in development, including five vaccines in preclinical trials, an oral monovalent vaccine (Vaxart, Inc.) that recently completed a phase IB clinical trial, and a bivalent intramuscular vaccine (Takeda Pharmaceutical Company Limited) in a phase IIB clinical trial. However, no norovirus vaccines are currently available on the market. In this commentary we aim to describe some of the barriers faced in norovirus vaccine development, particularly focusing on vaccine effectiveness and defining the target population.

Estimating the incidence of norovirus acute gastroenteritis among US and European international travelers to areas of moderate to high risk of traveler's diarrhea: a prospective cohort study protocol

Background

Acute gastroenteritis (AGE) is the leading cause of illness among returning travelers seeking medical care. Multiple types of enteric pathogens can cause travel-acquired AGE and, while bacterial pathogens have a predominant role, the importance of viruses, such as norovirus, is increasingly recognized. There is a lack of information on travel-acquired norovirus incidence among symptomatic and asymptomatic individuals irrespective of healthcare-seeking behavior. Our aim is to estimate the incidence of travel-acquired AGE due to norovirus and to characterize the burden of disease among international travelers from the United States and Europe.

Methods

We describe a prospective cohort study implemented in five US and European sites to estimate the role of AGE due to norovirus among adult international travelers. We enrolled individuals aged 18 years and older who are traveling to regions of moderate-high risk of AGE, or via cruise ship with an international port stop, with a trip duration of 3–15 days. The study will generate a wide range of health and travel-related data for pre-, during, and up to 6-months post-travel. We will identify laboratory-confirmed travel-acquired norovirus infections among both symptomatic and asymptomatic individuals from self-collected whole stool samples tested via quantitative RT-PCR. Coinfections will be identified in a subset of travelers with AGE using a multiplex molecular-based assay.

Discussion

This study is unique in design and breadth of data collected. The prospective collection of health and behavioral data, as well as biologic samples from travelers irrespective of symptoms, will provide useful data to better understand the importance of norovirus AGE among international travelers. This study will provide data to estimate the incidence of norovirus infections and AGE and the risk of post-infectious sequelae in the 6-month post-travel period serving as a baseline for future norovirus AGE vaccination studies. This study will contribute valuable information to better understand the role of norovirus in travel-acquired AGE risk and the impact of these infections on a broad set of outcomes.

The role of dependency in a norovirus outbreak in a nursing home

PURPOSE

The objectives of the epidemiological investigation were to describe factors associated with prolonged transmission of acute gastroenteritis in a nursing home during a norovirus outbreak.

METHODS

A retrospective cohort study was conducted among residents (N = 89) and staff members (N = 86) of the nursing home. Outbreak description was performed in both residents and staff members. Among residents, attack rates and relative risks and their 95% confidence interval (95% CI) associated with different identified risk factors including consumption of normal, mixed and choped meal, score of dependency were calculated. A multivariate logistic regression model was fitted to assess the independent association between risk factors and the occurrence of acute gastroenteritis over the entire outbreak duration. Environmental investigations and review of practices were carried out among staff.

RESULTS

Respectively 49/89 respondent residents (AR 58%) and 9/47 respondent staff members (AR 19%) reported gastrointestinal symptoms between September 17 and October 21, 2016. Norovirus type II was isolated in five stool samples. Residents with dependency score (Gir) below 4 were at higher risk of acute gastroenteritis [RR 2.1 (95% CI 1.1-4.1)] compared to those autonomous. It was the only identified risk factor. In addition, the review of practices in staff identified several breaks in the application of hygiene control standards including misuse of personal protective equipment (gloves were not changed between caring for different patients), inappropriate hand hygiene technique, and disinfection of environmental surfaces with an ineffective product on norovirus.

CONCLUSIONS

This episode reminds the importance of early recognition of acute gastroenteritis cases and the implementation of rigorous management measures in order to limit the spread of the epidemic in a highly vulnerable dependent population.

Norovirus Outbreak Associated with Swimming in a Recreational Lake Not Influenced by External Human Fecal Sources in The Netherlands, August 2012

Swimming in fecally contaminated recreational water may lead to gastrointestinal illness. A recreational water-associated outbreak of norovirus (NoV) infections affecting at least 100 people in The Netherlands occurred in August 2012. Questionnaire responses from patients indicated swimming in recreational lake Zeumeren as the most likely cause of illness. Most patients visited the lake during the weekend of 18–19 August, during which the weather was exceptionally warm (maximum temperatures 32–33 °C), and visitor numbers elevated. Patients, mostly children, became ill with gastroenteritis 1–6 days (median 2 days) after exposure. Four stool samples from patients were NoV GI positive. Subsurface sandy soil from one of the beaches where most patients swam was NoV GI positive; the water sample was negative. The epidemiological curve and the timeline of investigation based on reported symptoms demonstrate the difficulty in discovering the source in recreational water outbreaks. A NoV outbreak in a recreational lake that is not subjected to external fecal contamination sources shows the need for active communication about human shedding of viruses during and after diarrheal episodes and the advice to refrain from swimming, even a few weeks after the symptoms have resolved.

Persistence of Systemic Murine Norovirus Is Maintained by Inflammatory Recruitment of Susceptible Myeloid Cells

Viral persistence can contribute to chronic disease and promote virus dissemination. Prior work demonstrated that timely clearance of systemic murine norovirus (MNV) infection depends on cell-intrinsic type I interferon responses and adaptive immunity. We now find that the capsid of the systemically replicating MNV strain CW3 promotes lytic cell death, release of interleukin-1α, and increased inflammatory cytokine release. Correspondingly, inflammatory monocytes and neutrophils are recruited to sites of infection in a CW3-capsid-dependent manner. Recruited monocytes and neutrophils are subsequently infected, representing a majority of infected cells in vivo. Systemic depletion of inflammatory monocytes or neutrophils from persistently infected Rag1-/- mice reduces viral titers in a tissue-specific manner. These data indicate that the CW3 capsid facilitates lytic cell death, inflammation, and recruitment of susceptible cells to promote persistence. Infection of continuously recruited inflammatory cells may be a mechanism of persistence broadly utilized by lytic viruses incapable of establishing latency.

An unusual outbreak of norovirus associated with a Halloween-themed swimming pool party in England, 2016

In October 2016, an outbreak of norovirus occurred among attendees of a Halloween-themed party at a public swimming pool in the south-east of England. Norovirus genogroup II was confirmed in 11 cases. In the retrospective cohort study of pool users, 68 individuals (37 female and 31 male), with a median age of 11 years (range: 0–50 years), met the case definition of developing diarrhoea or vomiting between 6 and 72 h after the pool visit. Multivariable analysis showed that increasing age was associated with a reduced risk of illness (odds ratio = 0.91; 95% confidence interval: 0.83–0.99). Pool behaviours (swallowing water) and the timing of visit (attending pool party after automatic dosing system was switched off) were independently associated with increased risk. Environmental investigations revealed that the automatic dosing system was switched off to reduce chlorine levels to an intended range of 0.5–1 parts per million to facilitate the use of a commercial red dye. There was a lack of compliance with the operator's own pool operating procedures, particularly on maintaining effective chlorine levels in pool water, recording of test results and recording of actions undertaken. This outbreak highlights the risks of lowering chlorine levels when using pool water colourants.

Nitazoxanide Inhibits Human Norovirus Replication and Synergizes with Ribavirin by Activation of Cellular Antiviral Response

Norovirus is the main cause of viral gastroenteritis worldwide. Although norovirus gastroenteritis is self-limiting in immunocompetent individuals, chronic infections with debilitating and life-threatening complications occur in immunocompromised patients. Nitazoxanide (NTZ) has been used empirically in the clinic and has demonstrated effectiveness against norovirus gastroenteritis. In this study, we aimed at uncovering the antiviral potential and mechanisms of action of NTZ and its active metabolite, tizoxanide (TIZ), using a human norovirus (HuNV) replicon. NTZ and TIZ, collectively referred to as thiazolides (TZD), potently inhibited replication of HuNV and a norovirus surrogate, feline calicivirus. Mechanistic studies revealed that TZD activated cellular antiviral response and stimulated the expression of a subset of interferon-stimulated genes (ISGs), particularly interferon regulatory factor 1 (IRF-1), not only in a Huh7 cell-based HuNV replicon, but also in naive Huh7 and Caco-2 cells and novel human intestinal organoids. Overexpression of exogenous IRF-1 inhibited HuNV replication, whereas knockdown of IRF-1 largely attenuated the antiviral activity of TZD, suggesting that IRF-1 mediated TZD inhibition of HuNV. By using a Janus kinase (JAK) inhibitor, CP-690550, and a STAT1 knockout approach, we found that TZD induced antiviral response independently of the classical JAK-signal transducers and activators of transcription (JAK-STAT) pathway. Furthermore, TZD and ribavirin synergized to inhibit HuNV replication and completely depleted the replicons from host cells after long-term treatment. In summary, our results demonstrated that TZD combated HuNV replication through activation of cellular antiviral response, in particular by inducing a prominent antiviral effector, IRF-1. NTZ monotherapy or combination with ribavirin represent promising options for treating norovirus gastroenteritis, especially in immunocompromised patients.

Epidemiologic and Genotypic Distribution of Noroviruses Among Children With Acute Diarrhea and Healthy Controls in a Low-income Rural Setting

Background

Noroviruses are the most common cause of epidemic and endemic acute gastroenteritis (AGE) worldwide. The burden of norovirus disease in low-income settings is poorly understood.

Methods

We tested stool samples from children less than 5 years of age with diarrhea who were admitted in a rural hospital in Bangladesh from 2010–2012 and from matched, healthy controls from the same catchment area.

Results

Norovirus was detected in 109 (18%) of 613 children with diarrhea and in 30 (15%) of 206 healthy controls. Most (n = 118; 85%) norovirus infections belonged to genogroup II (GII). Of these, GII.4 viruses were identified in 36 (33%) of the cases and in 6 (21%) of the controls. Other major genotypes included GII.3 (13%), GII.6 (11%), and GII.13 (11%) in the cases and GII.6 (17%) and GII.2 (14%) in the controls. The greatest risk of severe norovirus disease (Vesikari score ≥11) was associated with GII.4 infections. GII.4 viruses were the predominant genotype detected during the winter (55%) and rainy season (23%), while GII.3 (19%) and GII.13 (19%) viruses were the most prevalent genotypes during the summer. Vomiting was significantly associated with GII.4 infections, while longer durations of diarrhea were associated with GI.3 infections.

Conclusions

Future studies are needed to understand the high rates of virus shedding in children without AGE symptoms.