An outbreak of food poisoning due to a genogroup I norovirus

Usefulness and Limitations of PFGE Diagnosis and Nucleotide Sequencing Method in the Analysis of Food Poisoning Pathogens Found in Cooking Employees

In the case of a food poisoning outbreak, it is essential to understand the relationship between cooking workers and food poisoning. Many biological diagnostic methods have recently been developed to detect food poisoning pathogens. Among these diagnostic tools, this study presents PCR-based pulsed-field gel electrophoresis and nucleotide sequencing diagnostic analysis results for diagnosing food poisoning outbreaks associated with cooking employees in Chungcheongnam-do, Republic of Korea. Pulsed-field gel electrophoresis was useful in identifying the food poisoning outbreaks caused by Staphylococcus aureus and Enteropathogenic Escherichia coli. In the case of Norovirus, nucleotide sequencing was used to identify the relationship between cooking workers and the food poisoning outbreak. However, it is difficult to determine whether cooking employees directly caused the food poisoning outbreaks based on these molecular biological diagnostic results alone. A system is needed to integrate epidemiological and diagnostic information to identify a direct correlation between the food poisoning outbreak and cooking employees.

Measuring transfer of human norovirus during sandwich production: Simulating the role of food, food handlers and the environment

Foodborne outbreaks associated with transmission of norovirus are increasingly becoming a public health concern. Foods can be contaminated with faecal material at the point of production or during food preparation, in both the home and in commercial premises. Transmission of norovirus occurs through the faecal-oral route, either via person-to-person contact or through faecal-contamination of food, water, or environmental surfaces. Understanding the role and pathways of norovirus transmission - either via food handlers' hands, contaminated foods or the environment - remains a key public health priority to reduce the burden of norovirus-associated gastroenteritis. However the proportion of norovirus that is typically transferred remains unknown. Understanding this is necessary to estimate the risk of infection and the burden of gastroenteritis caused by norovirus. In this paper we present a novel method of capture, concentration and molecular detection of norovirus from a wider range of complex food matrices than those demonstrated in existing published methods. We demonstrate that this method can be used as a tool to detect and quantify norovirus from naturally contaminated food, and for monitoring norovirus transfer between food handlers' gloved hands, food or the environment. We measure the effect of introducing contamination at different food production process stages, to the final food product, to determine whether this could cause infection and disease. Between 5.9 and 6.3 Log₁₀ cDNA copies/μl of norovirus GII were inoculated onto food handlers' gloved hands, food or the environment and 1.1-7.4% of norovirus contamination was recovered from all samples tested. When interpreted quantitatively, this percentage equates to levels predicted to be sufficient to cause infection and disease through consumption of the final food product, demonstrating a public health risk. Overall detection and quantification of norovirus from foods, food handlers' gloved hands and the environment, when suspected to be implicated in foodborne transmissions, is paramount for appropriate outbreak investigation.

Role of Food Handlers in Norovirus Outbreaks in London and South East England, 2013 to 2015

Outbreaks caused by norovirus infection are common and occur throughout the year. Outbreaks can be related to food outlets either through a contaminated food source or an infected food handler. Both asymptomatic and symptomatic food handlers are potentially implicated in outbreaks, but evidence of transmission is limited. To understand potential food handler transmission in outbreak scenarios, epidemiological and microbiological data on possible and confirmed norovirus outbreaks reported in London and South East England in a 2-year period were reviewed. One hundred eighty-six outbreaks were associated with a food outlet or registered caterer in this period. These occurred throughout the year with peaks in quarter 1 of study years. A case series of 17 outbreaks investigated by the local field epidemiological service were evaluated further, representing more than 606 cases. In five outbreaks, symptomatic food handlers were tested and found positive for norovirus. In four outbreaks, symptomatic food handlers were not tested. Asymptomatic food handlers were tested in three outbreaks but positive for norovirus in one only. Environmental sampling did not identify the causative agent conclusively in any of the outbreaks included in this analysis. Food sampling identified norovirus in one outbreak. Recommendations from this study include for outbreak investigations to encourage testing of symptomatic food handlers and for food and environmental samples to be taken as soon as possible. In addition, sampling of asymptomatic food handlers should be considered when possible. However, in light of the complexity in conclusively identifying a source of infection, general measures to improve hand hygiene are recommended, with specific education among food handlers about the potential for foodborne pathogen transmission during asymptomatic infection, as well as reinforcing the importance of self-exclusion from food handling activities when symptomatic.

The Where is Norovirus Control Lost (WINCL) Study: an enhanced surveillance project to identify norovirus index cases in care settings in the UK and Ireland

BACKGROUND

Norovirus outbreaks have a significant impact on all care settings; little is known about the index cases from whom these outbreaks initiate.

AIM

To identify and categorise norovirus outbreak index cases in care settings.

METHODS

A mixed-methods, multi-centre, prospective, enhanced surveillance study identified and categorised index cases in acute and non-acute care settings.

RESULTS

From 54 participating centres, 537 outbreaks were reported (November 2013 to April 2014): 383 (71.3%) in acute care facilities (ACF); 115 (21.4%) in residential or care homes (RCH) and 39 (7.3%) in other care settings (OCS). Index cases were identified in 424 (79%) outbreaks. Of the 245 index cases who were asymptomatic on admission and not transferred within/into the care setting, 123 (50%) had been an inpatient/resident for 4 days. Four themes emerged: missing the diagnosis, care service under pressure, delay in outbreak control measures and patient/resident location and proximity.

CONCLUSION

The true index case is commonly not identified as the cause of a norovirus outbreak with at least 50% of index cases being misclassified. Unrecognised norovirus cross-transmission occurs frequently suggesting that either Standard Infection Control Precautions (SICPs) are being insufficiently well applied, and or SICPs are themselves are insufficient to prevent outbreaks.

Person-to-person transmission of norovirus resulting in an outbreak of acute gastroenteritis at a summer camp

BACKGROUND

A significant proportion of norovirus (NV) gastroenteritis outbreaks described in the Spanish literature have been because of contaminated food or water.

AIM

This study describes an outbreak of acute gastroenteritis because of NV in which there was person-to-person transmission.

MATERIALS AND METHODS

A retrospective cohort study was carried out; we established the case definition for primary and secondary cases. An epidemiological survey was designed, including possible food exposures, and clinical and laboratory data. Water and stool samples were taken from affected individuals and food handlers. The presence of NV was detected using a reverse transcription-PCR assay. We analyzed the risk of gastroenteritis using relative risk and its 95% confidence interval as the measure of association, and estimated the basic reproductive number (R0).

RESULTS

The primary attack rate was 45.0%, with no significant differences between sexes. The secondary attack rate during the camp stay was 22.7%. The basic reproductive number for 5 days was R0=2.62. The most frequent symptoms were abdominal pain (85.7%) and vomiting (81.9%). Epidemiological analysis showed no association with food or drinking water. A total of 66.6% (8/12) of stool samples tested positive for NV (genogroup II).

CONCLUSION

Control measures in general, and hand hygiene in particular, should be extended to the families once the children return home, to prevent secondary cases in NV outbreaks.

Role of the Microbial Burden in the Acquisition and Control of Healthcare Associated Infections: The Utility of Solid Copper Surfaces

For more than a century, healthcare has been challenged to keep environmental surfaces clean to control microbes and improve patient outcomes. However despite an annual cost exceeding ten billion dollars cleaning with disinfection has done little to reduce the incidence of healthcare-associated infections (HAI). This chapter will review the scientific evidence delineating the role that the environment and healthcare workers play in the acquisition and movement of the microbes implicated in HAI and how through controlling the microbial burden of the built clinical environment it is possible to mitigate the rate of HAI acquisition. Specifically evidence demonstrating the effectiveness of solid copper surfaces for its ability to continuously limit the concentration of bacteria found on surfaces and objects within the built environment will be reviewed in concert with a discussion of how through the mitigation of the environmental burden copper surfaces are able to concomitantly reduce the incidence of HAI. Insights provided by this chapter are intended to facilitate an understanding and importance of the need to use a comprehensive or systems based approach to fight healthcare associated infections.

Norovirus transfer between foods and food contact materials

Human infective noroviruses (NoVs) are a worldwide leading cause of foodborne illness and are frequently spread via infected food handlers preparing and manipulating food products such as deli sandwiches. The objective of the current study was to determine the efficiencies whereby NoV could be transferred between surfaces associated with the preparation of manually prepared foods such as deli sandwiches. Nonfood surfaces included gloves and stainless steel discs, and boiled ham, lettuce, and a sandwich bun were the ingredients of the deli sandwich. Both NoV GII.4 and the murine NoV 1 (MNV-1, a cultivable human NoV surrogate) were included in the presented study. Transfer of NoV GII.4 and MNV-1 between surfaces was performed by pressing an inoculated donor surface against an acceptor surface. To evaluate the effect of subsequent contact, donor surfaces were pressed a second time to an identical acceptor surface. Subsequently, NoV GII.4 and MNV-1 were detected using real-time reverse transcription PCR assays and plaque assays, respectively. Transfer of both viruses from gloves to stainless steel was inefficient, and virus transfer from food products to stainless steel occurred with more variability for NoV GII.4 than for MNV-1. Virus transfer from the stainless steel discs to the gloves was substantially more efficient than from the gloves to the stainless steel. NoV GII.4 and MNV-1 transfer from food products to the gloves occurred with varying efficiencies, although this variation was more evident for NoV GII.4. The MNV-1 inoculum was significantly less efficiently transferred to the acceptor surface at the second contact, which was not the case for NoV GII.4. The obtained transfer efficiency data may provide insights into the transfer of NoV during preparation of foods and can be included in risk assessment models describing the transmission of NoVs in this context.

Hand hygiene perception among health care workers in Hungarian hospitals: prior to a nationwide microbiological survey

Transmission of pathogens via healthcare workers' (HCWs) hands is one of the most frequent means of spreading multi-resistant organisms and occurring healthcare-associated infections (HAIs) in hospitals. The role of contaminated hands in pathogen transmission was recognized by Hungarian physician, Ignác Semmelweis. Hand hygiene prevents cross-infections in hospitals, but numerous epidemiological and microbiology-based studies have documented low compliance of HCWs with this simple procedure. Furthermore, hand hygiene perception of HCWs plays an important role in determining hand hygiene compliance. Our aim was to describe the opinion of HCWs about their perception regarding hand hygiene practice. Our further goal was to strengthen a laboratory basis for bacterial backup control of nosocomial pathogens. A cross-sectional descriptive study was conducted between December 2010 and February 2011 in 13 participating hospitals in Hungary. HCWs know that there is correlation between contaminated hands and HAIs (83%), but neither the frequency (62%) nor the implementation (73%) of their hand hygiene performance are satisfying.We recommend that multimodal interventions - highlighted active microbiological surveillance of HCWs' hands - are the most suitable strategies to reduce the occurrence of HAIs and to determine their impact on cross-transmission of microorganisms and to overcome barriers of HCWs.

Application of a simple method using minute particles of amorphous calcium phosphate for recovery of norovirus from cabbage, lettuce, and ham

In this study, the amorphous calcium phosphate (ACP) method developed previously for calicivirus concentration from water was applied for norovirus detection from food. The viral recovery from cabbage, lettuce, or ham (10g of each) was firstly examined in seeding experiments with feline caliciviruses (FCVs). The viruses were concentrated by viral adsorption to ACP particles (0.3g) in the eluent solution (40ml) from foods, collection of the particles by centrifugation, followed by dissolution of the particles with 3.3M citric acid (3ml). In ham, FCV recovery was improved by addition of ascorbic acids into the eluent solution before ACP-particle adsorption. Quantitative real-time reverse transcription-PCR (qRT-PCR) revealed that FCV recoveries were 32-33%, 50-55%, and 37-46% from cabbage, lettuce, and ham, respectively, when seeded with 10(3)-10(4) viruses, and detection limits were estimated ∼10(3) genomic copies in all 3 foods. Subsequently, the ACP-concentration method was evaluated for norovirus (NoV) detection from these 3 foods. The recoveries and detection limit of NoVs determined by qRT-PCR were 12-41% and 10(3) (genomic copies) from cabbage, 30-57% and 10(3) from lettuce, and 20-26% and 10(4) from ham, when seeded with 10(3)-10(5) viruses. This simple method may be suitable for NoV detection from these foods.

A review of known and hypothetical transmission routes for noroviruses

Human noroviruses (NoVs) are considered a worldwide leading cause of acute non-bacterial gastroenteritis. Due to a combination of prolonged shedding of high virus levels in feces, virus particle shedding during asymptomatic infections, and a high environmental persistence, NoVs are easily transmitted pathogens. Norovirus (NoV) outbreaks have often been reported and tend to affect a lot of people. NoV is spread via feces and vomit, but this NoV spread can occur through several transmission routes. While person-to-person transmission is without a doubt the dominant transmission route, human infective NoV outbreaks are often initiated by contaminated food or water. Zoonotic transmission of NoV has been investigated, but has thus far not been demonstrated. The presented review aims to give an overview of these NoV transmission routes. Regarding NoV person-to-person transmission, the NoV GII.4 genotype is discussed in the current review as it has been very successful for several decades but reasons for its success have only recently been suggested. Both pre-harvest and post-harvest contamination of food products can lead to NoV food borne illness. Pre-harvest contamination of food products mainly occurs via contact with polluted irrigation water in case of fresh produce or with contaminated harvesting water in case of bivalve molluscan shellfish. On the other hand, an infected food handler is considered as a major cause of post-harvest contamination of food products. Both transmission routes are reviewed by a summary of described NoV food borne outbreaks between 2000 and 2010. A third NoV transmission route occurs via water and the spread of NoV via river water, ground water, and surface water is reviewed. Finally, although zoonotic transmission remains hypothetical, a summary on the bovine and porcine NoV presence observed in animals is given and the presence of human infective NoV in animals is discussed.

Evaluation of hygiene practices and microbiological status of ready-to-eat vegetable salads in Spanish school canteens

BACKGROUND

This study was conducted in eight Spanish school canteens during the period 2008-2009. Food handlers' practices, kitchen equipment, hygiene/sanitation conditions and handling practices were evaluated using checklists. In parallel, the microbiological quality and safety of ready-to-eat (RTE) vegetable salads were assessed. In addition, food contact surfaces and environmental air quality of different areas were analysed. The study determined the relationship between the microbiological quality of RTE foods and food handling practices, together with the degree of contamination of working surfaces and environmental contamination of processing and distribution areas.

RESULTS

Some deficiencies were found regarding the use and change of gloves, hand-washing and cleanliness of working surfaces. The microbial levels detected in the foods examined indicated the absence of pathogens in the samples analysed. Surface counts were higher on cutting boards and faucets, showing insufficient cleanliness procedures.

CONCLUSION

This study constitutes a descriptive analysis of the hygiene/sanitation conditions implemented in food service systems in eight Spanish school canteens. The results should help risk managers to better define control measures to be adopted in order to prevent foodborne infections.

Multiple norovirus outbreaks linked to imported frozen raspberries

In 2009, the number of foodborne norovirus outbreaks in Finland seemed markedly high, and many outbreaks seemed to be linked to imported frozen raspberries. We reviewed the data regarding all notified foodborne outbreaks in 2009 in Finland in order to assess the magnitude of the problem and to summarize the information on raspberry–linked outbreaks. Between March and August, 13 norovirus outbreaks affecting about 900 people could be linked to imported frozen raspberries. Two raspberry samples corresponding to two batches of raspberries were positive for norovirus. These two batches proved to have been the likely source in six of the 13 outbreaks. Analytical studies had not been conducted for six outbreaks, and virological test results were inconclusive in two. However, combining epidemiological and microbiological methods often enabled finding the source, as exemplified in investigation of a large school outbreak. To ensure prompt control measures in similar situations in the future, both aspects of outbreak investigations should be strengthened.

Norovirus as a foodborne disease hazard

Norovirus (NoV) is the most common cause of infectious gastroenteritis in the world. Gastroenteritis caused by bacterial and parasitic pathogens is commonly linked to food sources, but the link between NoV and contaminated foods has been more difficult to establish. Even when epidemiological information indicates that an outbreak originated with food, the presence of NoV in the suspect product may not be confirmed. If food is found to contain a common strain of NoV that circulates widely in the community, it is not possible to use strain typing to link the contamination to patient cases. Although food is certainly implicated in NoV spread, there are additional person-to-person and fomite transmission routes that have been shown to be important. NoV has an extremely low infectious dose, is stable in the environment, and resists disinfection. Cell culture methods are not available, so viability cannot be determined. Finally, many NoV outbreaks originate with when an infected food handler contaminates ready-to-eat food, which can be interpreted as foodborne or person-to-person transmission. This review will discuss both the physical characteristics of NoVs and the available epidemiological information with particular reference to the role of foods in NoV transmission.

Genetic characterization of genogroup I norovirus in outbreaks of gastroenteritis

In this study, we demonstrate that differences within the P2 domain of norovirus genogroup I (GI) strains can be used to segregate outbreaks which are unrelated, whereas complete conservation within this region allows tracking of strains that are part of a single outbreak and likely to have a common source.

A foodborne norovirus outbreak at a manufacturing company

Over 400 office workers from the same unit of a manufacturing company in Stockholm County, Sweden, fell ill with gastroenteritis. A retrospective cohort study of office workers in the affected unit demonstrated that canteen visitors on one day had an increased risk of illness [risk ratio (RR) 27·1, 95% confidence interval (CI) 15·7–46·8] compared to non-visitors. A second study, investigating canteen visitors' consumption of particular food items, showed that both tomatoes from the salad buffet (RR 5·6, 95% CI 3·2–9·6) and hamburgers (RR 4·9, 95% CI 2·4–9·8) were the most likely vehicles of infection. Norovirus GI.3 (Desert Shield) was identified in stool samples from three office workers and from a food handler who prepared the tomatoes for the salad buffet and hamburger ingredients before vomiting at the workplace on 12 November. The outbreak could have been prevented if the food items prepared by the food handler some hours before vomiting had not been served.

Microbiological safety of food in hospitals and other healthcare settings

Cases and outbreaks of foodborne infection in healthcare settings can result in serious illness, wastage of expensive medical treatments, spread of infection to other patients and staff and disruption of services. Providing nutritious meals for vulnerable people in healthcare settings involves a systematic approach to microbiological safety, as provided by hazard analysis and critical control point (HACCP) principles. The types of food served in healthcare settings should be selected to minimise the risk of foodborne infection.

Reported foodborne outbreaks due to noroviruses in Belgium: the link between food and patient investigations in an international context

The Belgian data for foodborne norovirus (NoV) outbreaks became available for the first time with the introduction of an extraction and detection protocol for NoV in the National Reference Laboratory for foodborne outbreaks in September 2006. In 2007, 10 NoV foodborne outbreaks were reported affecting 392 persons in Belgium. NoV became the most detected agent in foodborne outbreaks followed bySalmonella(eight foodborne outbreaks). The major implicated foods were sandwiches (4/10), where food handlers reported a history of gastroenteritis in two outbreaks. A food handler was implicated in the limited number of Belgian NoV outbreaks which is in accord with internationally recorded data. Forty foodborne and waterborne outbreak events due to NoV, epidemiological and/or laboratory confirmed, from 2000 to 2007 revealed that in 42·5% of the cases the food handler was responsible for the outbreak, followed by water (27·5%), bivalve shellfish (17·5%) and raspberries (10·0%).

Evaluación de dos métodos de detección antigénica por ELISA para el diagnóstico de brotes causados por norovirus

INTRODUCTION

The aim of this study was to assess two ELISA techniques for the detection of outbreaks of norovirus.

METHOD

One-hundred and sixty-five fecal samples from patients affected in 30 outbreaks were studied.

RESULTS

On the basis of a specific consensus criterion between techniques for confirming outbreaks, the sensitivity and specificity was respectively 80% and 90% for RIDASCREEN, and 80% and 100% for IDEIA.

CONCLUSION

These techniques could be useful for rapid detection of norovirus outbreaks in laboratories that lack molecular confirmation techniques.

Evidence-based model for hand transmission during patient care and the role of improved practices

Hand cleansing is the primary action to reduce health-care-associated infection and cross-transmission of antimicrobial-resistant pathogens. Patient-to-patient transmission of pathogens via health-care workers' hands requires five sequential steps: (1) organisms are present on the patient's skin or have been shed onto fomites in the patient's immediate environment; (2) organisms must be transferred to health-care workers' hands; (3) organisms must be capable of surviving on health-care workers' hands for at least several minutes; (4) handwashing or hand antisepsis by the health-care worker must be inadequate or omitted entirely, or the agent used for hand hygiene inappropriate; and (5) the caregiver's contaminated hand(s) must come into direct contact with another patient or with a fomite in direct contact with the patient. We review the evidence supporting each of these steps and propose a dynamic model for hand hygiene research and education strategies, together with corresponding indications for hand hygiene during patient care.