Surveillance of viral gastroenteritis in Japan: pediatric cases and outbreak incidents

Self-Powered Immunoassay of Norovirus in Human Stools by π-Electron-Rich Homojunction for Enhanced Charge Transfer

Norovirus (NoV) stands as a significant causative agent of nonbacterial acute gastroenteritis on a global scale, presenting a substantial threat to public health. Hence, the development of simple and rapid analytical techniques for NoV detection holds great importance in preventing and controlling the outbreak of the epidemic. In this work, a self-powered photoelectrochemical (PEC) immunosensor of NoV capsid protein (VP1) was proposed by the π-electron-rich carbon nitride homojunction (ER-CNH) as the photoanode. C4N2 ring derived from π-rich locust bean gum was introduced into the tri-s-triazine structure, creating a large π-delocalized conjugated carbon nitride homojunction. This strategy enhances the C/N atomic ratio, which widens light utilization, narrows the bandgap, and optimizes the electronic band structure of carbon nitride. By introduction of a π-rich conjugated structure, p-type domains were induced within n-type domains to build the internal electric field at the interface, thus forming a p-n homojunction to boost carrier separation and transfer. The ER-CNH photoanode exhibited excellent photoelectric performance and water oxidation capacity. Since VP1 inhibits the water oxidation of the ER-CNH photoanode, the open-circuit potential of the as-prepared PEC immunosensor system was reduced for detecting NoV VP1. The self-powered PEC immunosensor achieved a remarkably low detection limit (∼5 fg mL-1) and displayed high stability and applicability for actual stool samples. This research serves as a foundation concept for constructing immunosensors to detect other viruses and promotes the application of self-powered systems for life safety.

An outbreak of norovirus-associated acute gastroenteritis associated with contaminated barrelled water in many schools in Zhejiang, China

Objectives

More than 900 students and teachers at many schools in Jiaxing city developed acute gastroenteritis in February 2014. An immediate epidemiological investigation was conducted to identify the pathogen, infection sources and route of transmission.

Methods

The probable cases and confirmed cases were defined as students or teachers with diarrhoea or vomiting present since the term began in February 2014. An active search was conducted for undiagnosed cases among students and teachers. Details such as demographic characteristics, gastrointestinal symptoms, and drinking water preference and frequency were collected via a uniform epidemiological questionnaire. A case-control study was implemented, and odds ratios (ORs) and 95% confidence intervals were calculated. Rectal swabs from several patients, food handlers and barrelled water factory workers, as well as water and food samples, were collected to test for potential bacteria and viruses.

Results

A total of 924 cases fit the definition of the probable case, including 8 cases of laboratory-confirmed norovirus infection at 13 schools in Jiaxing city between February 12 and February 21, 2014. The case-control study demonstrated that barrelled water was a risk factor (OR: 20.15, 95% CI: 2.59–156.76) and that bottled water and boiled barrelled water were protective factors (OR: 0.31, 95% CI: 0.13–0.70, and OR: 0.36, 95% CI: 0.16–0.77). A total of 11 rectal samples and 8 barrelled water samples were detected as norovirus-positive, and the genotypes of viral strains were the same (GII). The norovirus that contaminated the barrelled water largely came from the asymptomatic workers.

Conclusions

This acute gastroenteritis outbreak was caused by barrelled water contaminated by norovirus. The outbreak was controlled after stopping the supply of barrelled water. The barrelled water supply in China represents a potential source of acute gastroenteritis outbreaks due to the lack of surveillance and supervision. Therefore, more attention should be paid to this area.

Evaluation of the Impact of the Source (Patient Versus Staff) on Nosocomial Norovirus Outbreak Severity

Objective:

To study the dependence of infection risk and outbreak size on the type of index case (ie, patient or staff).

Methods:

Nosocomial outbreaks were reviewed and categorized into those started by patients and those started by staff. Infection risks and outbreak sizes were evaluated taking into account the index case category.

Results:

Of the 30 nosocomial outbreaks of norovirus with person-to-person transmission, 20 (67%) involved patients as the index cases. Patient-indexed outbreaks affected significantly more patients than did staff-indexed outbreaks (difference in means, 16.25; 95% confidence interval [CI95], 5.1 to 27.0). For the numbers of affected staff, no dependence on the index case category was detectable (difference in means, -1.05; CI95, -9.0 to 6.9). For patients exposed during patient-indexed outbreaks, the risk of acquiring a norovirus infection was approximately 4.8 times as high as the corresponding risk for patients exposed during staff-indexed outbreaks (odds ratio [OR], 4.79; CI95,1.82 to 8.28). The infection risk for exposed staff during patient-indexed outbreaks was approximately 1.5 times as high as the corresponding risk during staff-indexed outbreaks (OR, 1.51; CI95, 0.92 to 2.49).

Conclusions:

Patient-indexed norovirus outbreaks generally affect more patients than do staff-indexed outbreaks. Staff appear to be similarly affected by both outbreak index category groups. This study demonstrates the importance of obtaining complete outbreak data, including the index case classification as staff or patient, during norovirus outbreak investigations. Such information may be useful for further targeting prevention measures.

Blood group substances as potential therapeutic agents for the prevention and treatment of infection with noroviruses proving novel binding patterns in human tissues

Blood group-related glycans determining ABO and Lewis blood groups are known to function as attachment factors for most of the norovirus (NoV) strains. To identify binding specificity of each NoV, recombinant norovirus-like particles (VLPs) and human saliva samples with different ABO, Lewis phenotypes and secretor status have been commonly applied. When binding specificities of VLPs prepared from 16 different genotypes of NoVs in GI and GII genogroups were characterized in samples of human gastric mucosa compared to human saliva based on blood group phenotypes, considerable differences were observed for several strains. Novel binding specificities determined by an ELISA using preparations from human gastric mucosa were also ascertained by immunohistochemical analyses using human jejunal mucosa, widely believed to be susceptible to NoV infection. Further, A, B and O(H) blood group substances prepared from porcine and squid tissues were found to be effective for preventing ABO blood group-specific binding of VLPs to both saliva and mucosa samples. Therefore, these blood group substances might have potential for the prevention and treatment of NoV infection.

Immunomagnetic Capture RT-PCR for Detection of Norovirus from Foods Implicated in a Foodborne Outbreak

In February 2001, an outbreak of acute gastroenteritis due to Norovirus (NV) occurred among employees of 11 companies in Aichi Prefecture. The illness was strongly associated with eating a delivered box-lunch. The use of magnetic beads coated with the antibody to the baculovirus-expressed recombinant capsid proteins of the Chiba virus (rCV) facilitated capture of NV from the food items implicated in the outbreak. Following immunomagnetic capture, NV bound to the beads was detected by reverse transcriptionpolymerase chain reaction (RT-PCR). Of the nine food items tested, two were positive for a genogroup 1 NV. Sequence analysis of RT-PCR products indicated that the nucleotide sequences of NV strains from foods were almost identical to those of NV strains detected in stool samples of ill patients. As the immunocapture RTPCR method is simple and easy to perform, this technique should be useful for the detection of NV from outbreak-implicated foods.

Proportion of Sporadic Gastroenteritis Cases Caused by Rotavirus, Norovirus, Adenovirus and Bacteria in Japan from January 2000 to December 2003

Many kinds of virus and bacterium have been identified as pathogens that cause sporadic gastroenteritis (SG). Among the pathogens, rotavirus (RV), norovirus (NV; previously known as Norwalk-like virus), and adenovirus (AdV) types 40/41 have been considered as the prevalent viruses implicated in the aetiology of childhood gastroenteritis. In the present study, we attempted to estimate monthly proportions of SG cases caused by the viral agents (RV, NV, AdV and other viruses (OV)) and bacterial agents in the whole of Japan. The estimation was carried out by using time series data of the incidence of SG and the viral and bacterial agents of SG, which were collected by a nationwide surveillance system in Japan from January 2000 to December 2003. It was confirmed that, in the dominant period of RV and NV, the proportion of RV-associated SG and that of NV-associated SG indicate almost same level with each other: 46-69% during February-May for RV, and 41-75% during October-December for NV.

Detection and Phylogenetic Analysis of Norovirus inCorbicula flumineain a Freshwater River in Japan

To study the molecular epidemiology of noroviruses (NoVs) in bivalves residing in freshwater rivers, we detected, quantified and phylogenetically analyzed the NoV genome in purified concentrates obtained from the gills and digestive diverticula of Corbicula fluminea in a freshwater river in Gunma Prefecture, Japan. We detected the NoV genome in 35 of the 58 C. fluminea samples. Based on our phylogenetic analysis, the NoV genome detected in the samples was classified into 4 genotypes (GI/1, GI/2, GI/3 and GI/4) in genogroup I and 5 genotypes (GII/3, GII/4, GII/5, GII/8 and GII/12) in genogroup II. The phylogenetic tree showed wide genetic diversity among the genogroups. In addition, more than 10(4) copies of the NoV genome were detected in 2 of 35 samples. These results suggest that the freshwater bivalve C. fluminea is a reservoir for NoVs, similar to seawater bivalves such as oysters.

Genotyping ofNorovirusStrains Detected in Outbreaks between April 2002 and March 2003 in Osaka City, Japan

Noroviruses (NVs) are the major cause of food- and waterborne nonbacterial gastroenteritis in Japan. Between April 2002 and March 2003, a total of 111 fecal specimens from 40 outbreaks of acute nonbacterial gastroenteritis in Osaka City, Japan were subject to NV detection. Seventy-two samples (64.9%) from 31 outbreaks (77.5%) were NV positive by a real time reverse transcription (RT)-PCR assay. To further determine the genotype of individual NV strains, we sequenced the capsid N-terminal/shell (N/S) domain of some representative strains from each outbreak. The 51 NV strains detected in this study were segregated into 15 genotypes (6 in genogroup I and 9 in genogroup II), and GII/5 genotype NV was a dominant outbreak genotype.

Genotyping and Quantitation of Noroviruses in Oysters from Two Distinct Sea Areas in Japan

Norovirus (NV) is a causative agent of acute gastroenteritis in humans, and shellfishes including oysters act as major vehicles of the virus. To investigate the genetic characteristics of NVs, we collected 1,512 oysters for raw consumption between October 2002 and March 2005 from two distinct areas (area A: the Sanriku Sea area; area B: the Setouchi Sea area). We detected the capsid gene and subjected it to phylogenetic analysis. By further quantification of the copy number of the genome by using real-time PCR, the NV capcid gene was detected in approximately 5% of the oysters, and they showed wide diversity. Two percent of the oysters from area B showed relatively large number of NVs, i.e., over 100 copies of capsid gene/oyster, whereas this was not observed in area A. Most of the detected NVs from oysters and humans were genetically related when the capsid region was compared. These results suggested that NVs obtained from humans and those obtained from oysters showed a potential relationship to each other and that some populations of Japanese oysters accumulated a relatively large number of NVs.

Two gastroenteritis outbreaks caused by GII Noroviruses: host susceptibility and HBGA phenotypes

Noroviruses (NoVs) cause epidemic acute gastroenteritis, in which histo-blood group antigens (HBGAs) may play an important role in the host susceptibility. To further explore this issue, two outbreaks of acute gastroenteritis caused by a GII.4 and a GII.3 NoV, respectively, in China in 2009 were studied. Stool and saliva samples from symptomatic patients and water samples from the outbreak facilities were collected. RT-PCR showed that 23 out of 33 (GII.4 outbreak) and 12 out of 13 (GII.3outbreak) stool samples were NoV positive. For the GII.4 outbreak the NoV sequences of stool and water samples were from an identical GII.4 strain, while the same GII.3 NoV sequences were found in five stool samples from the GII.3 outbreak. The HBGA phenotypes (A, B, Le(a), Le(b), Le(x), and Le(y)) of all saliva samples were determined, which revealed both secretors and nonsecretors in the symptomatic groups of the two outbreaks. In the GII.3 outbreak, type O individuals appeared less susceptible, while the type A may be more at risk of infection. However, No preference of HBGAs was observed in the GII.4 outbreak. The observation that nonsecretors were infected in both outbreaks differed from the previous results that nonsecretors are resistant to these two GII NoVs.

Shellfish-borne viral outbreaks: a systematic review

Investigations of disease outbreaks linked to shellfish consumption have been reported in the scientific literature; however, only few countries systematically collate and report such data through a disease surveillance system. We conducted a systematic review to investigate shellfish-borne viral outbreaks and to explore their distribution in different countries, and to determine if different types of shellfish and viruses are implicated. Six databases (Medline, Embase, Scopus, PubMed, Eurosurveillance Journal and Spingerlink electronic Journal) and a global electronic reporting system (ProMED) were searched from 1980 to July 2012. About 359 shellfish-borne viral outbreaks, alongside with nine ProMED reports, involving shellfish consumption, were identified. The majority of the reported outbreaks were located in East Asia, followed by Europe, America, Oceania, Australia and Africa. More than half of the outbreaks (63.6 %) were reported from Japan. The most common viral pathogens involved were norovirus (83.7 %) and hepatitis A virus (12.8 %). The most frequent type of consumed shellfish which was involved in outbreaks was oysters (58.4 %). Outbreaks following shellfish consumption were often attributed to water contamination by sewage and/or undercooking. Differences in reporting of outbreaks were seen between the scientific literature and ProMED. Consumption of contaminated shellfish represents a risk to public health in both developed and developing countries, but impact will be disproportionate and likely to compound existing health disparities.

Bioluminescent enzyme immunoassay for the detection of norovirus capsid antigen

An ultrasensitive and fully automated bioluminescent enzyme immunoassay (BLEIA) was developed for the detection of norovirus (NV) capsid antigen. In the evaluation tests with recombinant virus-like particles, the BLEIA demonstrated broad reactivity against several NV genotypes (genotypes 1, 3, 4, 7, 8, and 12 in genogroup I [GI] and genotypes 1, 2, 3, 4, 5, 6, 12, and 13 in GII), a wide dose-response range from 0.25 pg/ml to 10,000 pg/ml, and good reproducibility with low coefficients of variation (CVs) (within-run CVs of <2.8%, between-day CVs of <3.7%). In the evaluation tests with NV-positive fecal samples, a good correlation (y = 0.66x - 3.21, r = 0.84) between the BLEIA and real-time quantitative reverse transcription-PCR was obtained. Furthermore, in the dilution test with NV specimens, the analytical sensitivity of NV was estimated to be 10(5) to 10(6) copies/g of fecal sample, indicating that the analytical sensitivity of the BLEIA is comparable to that of commercially available molecular methods. All assay steps are fully automated, the turnaround time is 46 min, and the throughput of the assay is 120 tests/h. These results indicate that the BLEIA is potentially useful for the rapid diagnosis of NV in epidemic and sporadic gastroenteritis.

Impact of ambient temperature on children's health: a systematic review

Children are vulnerable to temperature extremes. This paper aimed to review the literature regarding the relationship between ambient temperature and children's health and to propose future research directions. A literature search was conducted in February 2012 using the databases including PubMed, ProQuest, ScienceDirect, Scopus and Web of Science. Empirical studies regarding the impact of ambient temperature on children's mortality and morbidity were included. The existing literature indicates that very young children, especially children under one year of age, are particularly vulnerable to heat-related deaths. Hot and cold temperatures mainly affect cases of infectious diseases among children, including gastrointestinal diseases, malaria, hand, foot and mouse disease, and respiratory diseases. Pediatric allergic diseases, like eczema, are also sensitive to temperature extremes. During heat waves, the incidences of renal disease, fever and electrolyte imbalance among children increase significantly. Future research is needed to examine the balance between hot- and cold-temperature related mortality and morbidity among children; evaluate the impacts of cold spells on cause-specific mortality in children; identify the most sensitive temperature exposure and health outcomes to quantify the impact of temperature extremes on children; elucidate the possible modifiers of the temperature and children's health relationship; and project children's disease burden under different climate change scenarios.

Complete genomic sequence analysis of norovirus isolated from South Korea

The complete nucleotide and deduced amino acid sequences of the RNA genome of a recently isolated norovirus (NoV) from Korea, designated Hu/GII-4/CBNU2/2007/KR (CBNU2), were determined and characterized by phylogenetic comparison with several genetically diverse NoV sequences. The RNA genome of CBNU2 is 7,560 nucleotides in length, excluding the 3' poly (A) tract. It includes three open reading frames (ORFs): ORF1, which encodes the nonstructural polyprotein (5-5,104); ORF2, which encodes VP1 (5,085-6,707); and ORF3, which encodes VP2 (6,707-7,513). ORF2-based phylogenetic analysis revealed that CBNU2 belonged to the GII.4 genotype, the most prevalent genotype, and formed a cluster with NoVs isolated from Asian regions, between 2006 and 2008. Comparative analysis with the consensus sequence of 207 completely sequenced NoV genomes showed 47 mismatched nucleotides: 26 in ORF1, 14 in ORF2, and 7 in ORF3, resulting in 8 amino acid changes: 3 in ORF1, 2 in ORF2, and 3 in ORF3. Phylogenetic analysis with full genome ORF1, ORF2, and ORF3 nucleotide sequences obtained from CBNU2 and each of the other representative NoV genomes suggested that CBNU2 had not undergone recombination with any of the other NoVs. A SimPlot analysis further supported this finding.

Prevalence of norovirus infection in children and adults with acute gastroenteritis, Tehran, Iran, 2008-2009

Noroviruses are one of important agents that cause acute viral gastroenteritis worldwide. These viruses are belonging to Caliciviridae family and are genetically diverse. To date, there is no valuable data about prevalence of norovirus infection and the dominant genogroup/genotype among Iranian population. The objective of this study was to determine the frequency of norovirus infection in Iranian patients with gastroenteritis referred to three hospitals of Tehran and to specify the dominant genogroup/genotype of this virus among our study population. A total of 293 patients with acute gastroenteritis were included in the study. Detection of norovirus was performed using RT-PCR method and confirmed by direct sequencing with specific designed primers for capsid region of norovirus genome. Phylogenetic analysis was performed using the neighbor-joining method. Norovirus strains identified in our study were subsequently categorized according to previously defined genogroup/genotypes. Of these, norovirus GII was dominant genogroup. Sixty-five percent (17 of 26) of positive samples were determined as GII and 35% (9 of 26) were determined as GI, respectively, in 2008-2009. And among 8 sequenced strains of genogroup II the most frequent genotype was GII.3. The results of this study indicated that norovirus must be considered as one of the infectious causes of acute gastroenteritis among Iranian population. We also found that GII.3 is more prevalent in our study population. To the best of our knowledge there is limited data about the role of noroviruses in children and adults' acute gastroenteritis among Iranian patients and this prevalence and genotyping report of norovirus infection could be remarkable for further studies.

Updates on the genetic variations of norovirus in sporadic gastroenteritis in Chungnam Korea, 2009-2010

Previously, we explored the epidemic pattern and molecular characterization of noroviruses (NoVs) isolated in Chungnam, Korea in 2008, and the present study extended these observations to 2009 and 2010. In Korea, NoVs showed the seasonal prevalence from late fall to spring, and widely detected in preschool children and peoples over 60 years of age. Epidemiological pattern of NoV was similar in 2008 and in 2010, but pattern in 2009 was affected by pandemic influenza A/H1N1 2009 virus. NoV-positive samples were subjected to sequence determination of the capsid gene region, which resolved the isolated NoVs into five GI (2, 6, 7, 9 and 10) and eleven GII genotypes (1, 2, 3, 4, 6, 7, 8, 12, 13, 16 and 17). The most prevalent genotype was GII.4 and occupied 130 out of 211 NoV isolates (61.6%). Comparison of NoV GII.4 of prevalent genotype in these periods with reference strains of the same genotype was conducted to genetic analysis by a phylogenetic tree. The NoV GII.4 strains were segregated into seven distinct genetic groups, which are supported by high bootstrap values and previously reported clusters. All Korean NoV GII.4 strains belonged to either VI cluster or VII cluster. The divergence of nucleotide sequences within VI and VII intra-clusters was > 3.9% and > 3.5%, respectively. The "Chungnam(06-117)/2010" strain which was isolated in June 2010 was a variant that did not belong to cluster VI or VII and showed 5.8-8.2%, 6.2-8.1% nucleotide divergence with cluster VI and VII, respectively.

Genetic diversity of noroviruses in Chinese adults: potential recombination hotspots and GII-4/Den Haag-specific mutations at a putative epitope

Little is known about the role of noroviruses (NVs) in sporadic cases of acute gastroenteritis in adults. The GII-4 NVs are currently the globally dominant genotype with diverse genetic makeups. The mechanism(s) underlying the persistence and rapid evolution of the viruses are not yet clear. In this study we collected 547 specimens from adult of >14 years of age with acute gastroenteritis in Beijing, China from September 2007 to Febraury 2008. NVs were screened and sequenced to determine their genotypes. Bioinformatics methods were used to detect NV recombination and their breakpoints. The residue variations of the capsid proteins between GII-4/Den Haag and previous predominant variants of GII-4 were compared to identify mutations that are likely important for current epidemic wave. Putative epitopes were predicted based upon the crystal structure. 106 (19.4%) NVs were identified among 547 specimens. While GII-4 remains predominant, at least six other genotypes were observed. Two recombinant types were identified with both predicted breakpoints locating within the 24-27 bp region upstream the start codon of ORF2. We found the emergent mutations H414P/Q of the capsid protein are specific for GII-4/Den Haag and this site lies within a predicted antibody-binding epitope. Our data demonstrated that NVs were an important cause of acute gastroenteritis in Chinese adults. The shared breakpoints identified in the GI and GII recombinants imply the presence of recombination hotspots in NVs. The mutations at residue 414 and its location within a putative antigenic epitope suggested a possible mechanism that may allow GII-4 NVs to escape from herd immunity.

[An outbreak of gastroenteritis caused by norovirus: suspected due to dust transmission]

A norovirus gastroenteritis outbreak at a wedding reception hall in Nagano Prefecture in April 2008 affected that hall's reception participants and waiters, but not waiters or food handlers at another hall. To determine the infection route, dust in three vacuum cleaners used to clean the venue were tested for norovirus using real-time reverse transcriptase polymerase chain reaction (RT-PCR), with norovirus RNA detected from all three. Sequencing analysis of a 280-nt portion of the capsid region showed that 9 specimens from infected reception participants and waiters and dust samples had 100% nucleotide identity. This suggests that the infection route was dust transmission, that the reception venue floor had been contaminated with norovirus, and that participants and staff had been exposed to norovirus in dust during the wedding reception. Dust thus requires specific attention as a potential infection source because norovirus cDNA copies were 1.7 x 10(4) to 1.6 x 10(5) per gram in dust specimens.

Quantification of Norwalk virus inocula: Comparison of endpoint titration and real-time reverse transcription-PCR methods

Human noroviruses (NoV) are the leading cause of epidemic acute gastroenteritis. In order to fully characterize features such as persistence and infectious dose, precise quantification of virus concentration is necessary. The purpose of this study was to compare two methods [endpoint titration RT-PCR and quantitative RT-PCR (RT-qPCR)] with respect to quantification of Norwalk virus (NV) in inocula made from purified stock suspensions of human fecal specimens. A full-length NV RNA transcript was developed to facilitate quantification using RT-qPCR and provided log linear detection in the range of 49-4.9 x 10(4) genome equivalent copies (GEC) per reaction. Endpoint titration RT-PCR was used to estimate PCR detection units, and RT-qPCR was used to estimate genome copies in two NV inocula (8fIIa and 8fIIb) used in previous human challenge studies. Overall, RT-qPCR was 1.1-1.6 log(10) more sensitive (lower detection limit) than endpoint titration RT-PCR when the same RNA release method, PCR primers and thermocycle program were used. These findings have important implications for many experimental interpretations, not the least of which is estimating the median infectious dose in human challenge studies.

Weather variability and paediatric infectious gastroenteritis

Investigations of the relationship between weather variability and infectious gastroenteritis (IG) are becoming increasingly important in light of international interest in the potential health effects of climate change. However, few studies have examined the impact on children, despite the fact that children are considered particularly vulnerable to climate change. We acquired data about cases of IG in children aged <15 years and about weather variability in Fukuoka, Japan from 2000 to 2008 and used time-series analyses to assess how weather variability affected IG cases, adjusting for confounding factors. The temperature-IG relationship had an inverted V shape, with fewer cases at temperatures lower and higher than ~13°C. Every 1°C increase in temperature below the threshold (13°C) was associated with a 23·2% [95% confidence interval (CI) 16·6-30·2] increase, while every 1°C increase in temperature above the threshold (13°C) was associated with an 11·8% (95% CI 6·6-17·3) decrease in incidence. The increase in cases per 1% drop in relative humidity was 3·9% (95% CI 2·8-5·0). The percentage increase of IG cases was greatest in the 0-4 years age group and tended to decrease with increasing age. We found a progressive reduction in weather-related IG cases in children aged >4 years. Our results suggest that public health interventions aimed at controlling weather-related IG may be most effective when focused on young children.

Complete genome sequence and phylogenetic analysis of a recombinant Korean norovirus, CBNU1, recovered from a 2006 outbreak

We have determined the complete nucleotide and deduced amino acid sequences of the RNA genome of CBNU1, a human norovirus (NoV) recovered from a 2006 outbreak in South Korea. The genome of 7547 nucleotides, excluding a 3'-poly(A) tail of 11-105 nucleotides, encodes three overlapping open reading frames (ORFs): ORF1 (nucleotides 5-5104), ORF2 (nucleotides 5085-6731), and ORF3 (nucleotides 6731-7495). In a comparison to 108 other currently available completely sequenced NoVs representing all five genogroups (GI-GV) except GIV, the CBNU1 strain was highly similar to GII.3 NoVs. Multiple sequence alignments of the completely sequenced NoV genomes revealed five hypervariable regions throughout their genomes: two in ORF1, one in ORF2, and two in ORF3. At both the nucleotide and amino acid levels, genome-based phylogenetic analyses invariably showed that the CBNU1 strain was most closely related to three GII.3 NoVs: the American Texas/TCH04-577 and the two Japanese Saitama U18 and Saitama U201 strains; furthermore, these genome-based phylogenetic topologies corresponded most closely to those based on the ORF2 genes, as compared to those based on the ORF1 and ORF3 genes. Subsequent ORF2-based phylogenetic analyses of a selection of 126 other NoVs representing all 19 GII genotypes, in combination with genome-based Simplot analyses, showed that the CBNU1 strain was a recombinant GII.3 NoV with a breakpoint at the ORF1/ORF2 junction between two putative parent-like strains, Guangzhou/NVgz01 and Texas/TCH04-577. Overall, the CBNU1 strain represents the first Korean human NoV whose genome has been completely sequenced and for which its relationship with a large panel of genetically diverse NoVs has been extensively characterized.

Norovirus gastroenteritis

Recent epidemiologic studies have shown that norovirus is one of the most frequent causes of acute nonbacterial gastroenteritis. Reverse-transcription polymerase chain reaction and nucleotide sequencing are the means by which the hundreds of norovirus strains have been identified, named, and classified into genogroups and genetic clusters. They are also the means by which a particular strain is traced from the source of an outbreak throughout its spread. These molecular techniques have been combined with classic epidemiology to investigate norovirus outbreaks in diverse settings, including hospitals, nursing homes, dining locations, schools, daycare centers, and vacation venues. Outbreaks are difficult to control because of the apparent ease of transmission through food, water, person-to-person contact, and environmental surfaces. Almost all patients with norovirus gastroenteritis recover completely, but hospital and nursing home outbreaks have been associated with morbidity and mortality. The diagnostic and management approach to an individual patient is to use clinical and epidemiologic findings to rule out "not norovirus." At the first sign that there is an outbreak, strict compliance with cleaning, disinfection, and work release guidelines is important to prevent further spread.

Clinical characteristics of rotavirus gastroenteritis in children in a medical center

BACKGROUND

Rotavirus is one of the major causes of severe gastroenteritis in infants and young children worldwide.

METHODS

We retrospectively analyzed the demographic and clinical profiles of rotavirus infection among children hospitalized in the Cathay General Hospital, Taiwan from May 2004 to April 2007. Children under 15 years of age with gastroenteritis were enrolled in the study and had stool specimens tested for the presence of rotavirus.

RESULTS

There were 238 participating patients, most of whom were aged 3-5 years (44%). The most common symptom was diarrhea (98.7%), and the peak month was May (20.4%). All patients were discharged alive with no complications.

CONCLUSION

Gastroenteritis due to rotavirus infection was found in older children between 6 and 12 years of age, as well as in hospitalized children between 3 and 5 years of age. Most cases occurred in the spring.

Norovirus gastroenteritis outbreak with a secretor-independent susceptibility pattern, Sweden

Nonsecretors were highly susceptible to norovirus GI.3 in a foodborne outbreak.

Norovirus (NoV) is recognized as the commonest cause of acute gastroenteritis among adults. Susceptibility to disease has been associated with histo-blood group antigens and secretor status; nonsecretors are almost completely resistant to disease. We report a foodborne outbreak of GI.3 NoV gastroenteritis that affected 33/83 (40%) persons. Symptomatic disease was as likely to develop in nonsecretors as in secretors (odds ratio [OR] 1.41, 95% confidence interval [CI] 0.46–4.36 vs. OR 0.71, 95% CI 0.23–2.18, p = 0.57). Moreover, no statistical difference in susceptibility was found between persons of different Lewis or ABO phenotypes. The capsid gene of the outbreak strain shares high amino acid homology with the Kashiwa645 GI.3 strain, previously shown to recognize nonsecretor saliva, as well as synthetic Lewis a. This norovirus outbreak affected persons regardless of secretor status or Lewis or ABO phenotypes.

Surveillance and risk factors of norovirus gastroenteritis among children in a southern city of China in the fall-winter seasons of 2003-2006

AIM

Noroviruses (NoVs) are an important cause of acute gastroenteritis but knowledge on the disease burden and epidemiology in children in the developing countries remains limited. In this study, we performed a surveillance of NoV gastroenteritis in children of China to address some of the questions.

METHODS

Faecal specimens from children (<5 years of age) at outpatient clinics of the Nan Fang Hospital in Guangzhou, China during the fall-winter seasons in 2003-2006 were tested for rotaviruses (RVs) and NoVs. A questionnaire on clinical records and hygiene habits was collected from each patient.

RESULTS

Among 957 stool specimens tested, 488 (51%) specimens were positive for RVs. NoVs were detected in 112 (24%) of the 469 RV negative specimens. The Genogroup II (GII), particularly GII-4, viruses were predominant. No significant difference of clinical symptoms, hospitalisation and patient care expenses were found between children infected with NoVs and RVs. Consumption of uncooked food is a risk for NoV infection. Contact with diarrhoea patients is a suspected risk factor. Cutting nails frequently is a protective factor against NoV infection.

CONCLUSIONS

NoVs are an important cause of acute gastroenteritis in children which need special attention of patient care at the clinics in addition to RVs. The awareness of those risk factors may help future disease control and prevention.

Antiviral activity of proanthocyanidin against feline calicivirus used as a surrogate for noroviruses, and coxsackievirus used as a representative enteric virus

Proanthocyanidin, which consists of (+) catechin, (-) epicatechin and their gallates (15%), (-) epicatechin gallate-dimers, -trimers, and -tetramers (80%), and (-) epicatechin gallate-pentamers, -hexamers, and -heptamers (5%), was evaluated for its antiviral activity against feline calicivirus F9 strain (FCV/F9), which is thought to be a surrogate for noroviruses, and coxsackievirus A7 strain (Cox.A7), which was selected as a representative enteric virus. To achieve a viral inactivation rate of 99% or greater after contact for 10 sec., at least 1 mg/ml and 10 mg/ml of proanthocyanidin were required against FCV/F9 and Cox.A7, respectively. Although the antiviral mechanism of proanthocyanidin is not clear at present, proanthocyanidin may be an effective disinfectant against enteroviruses such as noroviruses.

Molecular characterization of murine norovirus isolates from South Korea

The recently discovered murine norovirus (MNV) is an important surrogate virus for studying the human norovirus (NoV) because of its ability to replicate in conventional cell cultures using mouse macrophage cell lines. In addition, the impact of MNV is significant due to the high prevalence of MNV in commonly used laboratory animals in biomedical research. The prevalence and molecular characteristics of MNV could differ in various regions of the world. Therefore, the objectives of this study were (1) to determine the prevalence of MNV in animal laboratories in South Korea and (2) to compare and characterize novel MNV isolates with reported MNV isolates. We investigated 115 mouse specimens, including feces and tissues collected at five major animal facilities in South Korea, using both cell cultivation and RT-PCR assays. More than 20% of the investigated samples were positive for the virus by RT-PCR. When the complete genomes of two MNV isolates were sequenced and their sequences were compared to MNVs previously identified in North America and Germany, distinct nucleic acid sequences were identified in our new isolates.

Seroepidemiological study of norovirus infection in Aichi Prefecture, Japan

The serological prevalence of IgG antibody to seven NoV strains (GI.1, GI.4, GII.3, GII.4, GII.10, GII.12 and GII.15) among inhabitants aged 1-62 years of Aichi Prefecture, Japan was studied. Age-related seroprevalence was measured by ELISA using baculovirus-expressed recombinant VLP antigens. Seropositive rates for all seven VLP antigens gradually increased with age. Among the tested antigens, the highest seropositive rate was for the GII.4 strain. This result is consistent with the recent epidemic of NoV infection due to GII.4 strain in Japan.

Loop-mediated isothermal amplification (LAMP): a rapid, accurate, and cost-effective diagnostic method for infectious diseases

Loop-mediated isothermal amplification (LAMP) is an established nucleic acid amplification method offering rapid, accurate, and cost-effective diagnosis of infectious diseases. This technology has been developed into commercially available detection kits for a variety of pathogens including bacteria and viruses. The current focus on LAMP methodology is as a diagnostic system to be employed in resource-limited laboratories in developing countries, where many fatal tropical diseases are endemic. The combination of LAMP and novel microfluidic technologies such as Lab-on-a-chip may facilitate the realization of genetic point-of-care testing systems to be used by both developed and developing countries in the near future. This review will describe the historical, current, and future developments of such technologies.

Prevalence of norovirus and factors influencing virus concentrations during one year in a full-scale wastewater treatment plant

Norovirus (NoV) is a leading cause of acute gastroenteritis and is often spread via wastewater contamination. Little is known about how the wastewater treatment process affects norovirus, and which factors influence virus concentrations. To investigate this, we collected wastewater samples monthly during one year at eight different key sites at the municipal wastewater treatment plant in Gothenburg, Sweden. Virus particles were concentrated using ultracentrifugation, viral RNA was subsequently extracted, and transformed into cDNA by reverse transcription. The quantification was performed with real-time PCR assays for NoV genogroups I (GGI) and II (GGII), respectively. We found seasonal changes of NoV genogroups, with the highest concentration of NoV GGII during the winter months, and the highest concentration of NoV GGI during the summer months. Virus transmission in wastewater was more stable for NoV GGI, with NoV GGII demonstrating larger seasonal peaks. Virus reduction took place at similar rates in the primary settling, and in the activated sludge in combination with the secondary settling. Different physicochemical parameters and incoming virus concentrations were correlated to reduction of NoV between different treatment sites. This study gives new information about NoV transmission and virus reduction in a wastewater treatment plant.

Viral agents associated with acute gastroenteritis in children hospitalized with diarrhea in Lanzhou, China

BACKGROUND

Gastroenteritis is a major cause of childhood morbidity and mortality worldwide. Rotavirus, human caliciviruses (HucV), adenovirus, and astrovirus are recognized as common etiologies of acute gastroenteritis.

OBJECTIVES

To use antigen detection and molecular methods to determine the viral etiology of childhood diarrhea in Lanzhou, China, 2005-2007.

STUDY DESIGN

544 stool specimens were collected from children hospitalized with diarrhea. ELISA, RT-PCR, or PCR were used to detect viruses commonly causing diarrhea.

RESULTS

Group A rotavirus, norovirus, sapovirus, astrovirus, and adenovirus, were detected in 54.0%, 9.2%, 1.1%, 3.3%, and 4.4%, respectively. No group B or group C rotaviruses were detected. The relative contribution of these viruses changed greatly over 2 years. The percentage of rotavirus and adenovirus dropped from 61.2% and 5.4% to 47.6% and 1.4%, whereas HucV increased from 5.0% to 15.0%. G1 and P[8] were the predominant rotavirus strains, and P[6] was detected for the first time in this area. The predominant norovirus strain changed from GII3 to GII4, and the subtypes of GII4 changed from the Hunter strain to the variant 2006b strain.

CONCLUSIONS

The distribution of viruses and genotypes of individual viruses causing gastroenteritis in Lanzhou, China changed greatly during 2005-2007.

Development of a rapid high-throughput method for high-resolution melting analysis for routine detection and genotyping of noroviruses

We developed a simple, rapid, high-throughput detection and genotyping method for noroviruses using real-time reverse transcription-PCR (RT-PCR) and high-resolution melting (HRM) analysis to create a difference plot. The capsid gene was amplified by real-time RT-PCR in the presence of ResoLight HRM dye, a saturating DNA dye. Following optimization of the HRM assay conditions, the major norovirus genotypes were selected. Because we had only small quantities of the patient stool samples used in this study, we constructed plasmids for each genotype and used these to optimize the HRM assay. We selected six stool samples, each positive for one of the six dominant subtypes of noroviruses that have been circulating in Japan, namely, genotypes 4, 8, and 9 from genogroup 1 and genotypes 3, 4, and 10 from genogroup 2. The specific high-resolution derivate plot of the HRM assay for each plasmid was constructed by subtracting the melting-curve shape of the plasmid from the reference or base curve. The RNAs extracted from 14 clinical samples positive for small round structured viruses were then directly analyzed using the HRM assay. The HRM data from the clinical RNA samples corresponded with the genotype results obtained by RT-PCR and sequencing of the clinical samples. In addition, the HRM data from the clinical RNA samples corresponded with the HRM data from the six reference plasmid DNAs, indicating that this assay is useful for the direct detection and genotyping of noroviruses in clinical samples. This assay requires no multiplexing or hybridization probes and provides a new approach to the genetic screening of noroviruses in clinical virology laboratories.

Human noroviruses recognize sialyl Lewis x neoglycoprotein

The carbohydrate binding characteristics of a norovirus GII.3 (Chron1) and a GII.4 (Dijon) strain were investigated using virus-like particles (VLPs) and saliva samples from 81 individuals genotyped for FUT2 (secretor) and FUT3 (Lewis) and phenotyped for ABO and Lewis blood groups. The two VLPs showed a typical secretor-gene-dependent binding and bound significantly stronger to saliva from A, B, and AB than from O individuals (P < 0.0001 and P < 0.001) but did not bind to any samples from secretor-negative individuals. The GII.3 strain showed larger interindividual variation and bound stronger to saliva from B than from A(2) secretors (P < 0.01). When assaying for binding to neoglycoproteins, the GII.3 and GII.4 strains were compared with the Norwalk GI.1 prototype strain. Although all three strains bound to Lewis b (and H type 1 chain) glycoconjugates, only the two GII strains showed an additional binding to sialyl Lewis x. This novel binding was specific since the VLPs did not bind to structural analogs, e.g., Lewis x or sialyl Lewis a, but only to sialyl Lewis x, sialyl diLewis x and sialylated type 2 chain conjugates. In inhibition experiments, the sialyl Lewis x conjugate was the most potent inhibitor. The minimal requirement for this potential receptor structure is Neu5Ac alpha 3Gal beta 4(Fuc alpha 3)GlcNAc beta 3Gal beta- where Fuc is not absolutely necessary for binding. Our study shows that some human norovirus GII strains have at least two binding specificities: one secretor-gene-dependent related to alpha1,2-fucosylated carbohydrates and another related to alpha2,3-sialylated carbohydrates of the type 2 chain, e.g., sialyl Lewis x.

Coinfection of viral agents in Korean children with acute watery diarrhea

Currently, there are a few reports on viral coinfection that causes an acute watery diarrhea in Korean children. So, to evaluate the features of coinfectious viral agents in children with acute watery diarrhea, we enrolled 155 children with acute watery diarrhea from July 2005 to June 2006. Fecal samples were collected and evaluated for various viral infections such as rotavirus, norovirus, adenovirus and astrovirus. The mean (+/-standard deviation) age of the children was 2.71+/-2.37 yr. The detection rate of viral agents was most common in children between the ages of 1 and 3 yr. Rotavirus was detected in 63 children (41.3%), norovirus in 56 (36.2%), adenovirus in 11 (7.1%), and astrovirus in 1 (0.6%). Regarding rotavirus, there were 38 (60.3%) cases with monoinfection and 25 (39.7%) with coinfection. For norovirus, there were 33 (58.9%) cases with monoinfection and 23 (41.1%) with coinfection. Coinfection with rotavirus and norovirus was most common, and occurred in 20/155 cases (12.9%) including coinfection with adenovirus. So, rotavirus and norovirus were the most common coinfectious viral agents in our study population with acute watery diarrhea.

Recombinant norovirus implicated in gastroenteritis outbreaks in Hiroshima Prefecture, Japan

Norovirus (NoV) is a major etiological agent of acute gastroenteritis outbreaks worldwide. A total of 314 fecal specimens collected from patients of 39 NoV gastroenteritis outbreaks in Hiroshima Prefecture, Japan, between December 2001 and April 2006 were tested for the occurrence of recombinant NoVs. Sixteen genotypes (GI/1, GI/2, GI/4, GI/7, GI/8, GI/11, GI/14, GII/2, GII/3, GII/4, GII/5, GII/6, GII/8, GII/12, GII/14, and GII/untypeable) were detected in the 39 outbreaks based on capsid sequences and GII/4 was predominant recently. Twelve strains detected in 11 (28.2%) of the 39 outbreaks were suspected to be recombinants by using Simplot and Recco analyses and five recombinant genotypes, GII/4-GII/12 (five strains), GIIb-GII/3 (four strains), GII/4-GII/2 (one strain), GII/4-GII/14 (one strain), and GI/2-GI/8 (one strain), were identified based on RNA-dependent RNA polymerase and capsid sequences. None of the strains genotyped as GII/4 based on the capsid sequence was identified as a recombinant. The putative recombination points in the recombinant strains were placed either upstream or downstream of the open reading frame (ORF) 1 and ORF2 overlap. The present study indicates the following: (a) recombination among ORFs is common in nature, (b) the involvement of recombinant NoVs in gastroenteritis outbreaks is extensive even in a local area such as Hiroshima Prefecture, Japan, and (c) the conserved region (ORF1 and ORF2 overlap) has a meaningful function against the recombination event.

Rapid and sensitive detection of norovirus genomes in oysters by a two-step isothermal amplification assay system combining nucleic acid sequence-based amplification and reverse transcription-loop-mediated isothermal amplification assays

We developed a two-step isothermal amplification assay system, which achieved the detection of norovirus (NoV) genomes in oysters with a sensitivity similar to that of reverse transcription-seminested PCR. The time taken for the amplification of NoV genomes from RNA extracts was shortened to about 3 h.

Occurrence of norovirus infections unrelated to norovirus outbreaks in an asymptomatic food handler population

Norovirus (NV) is the most common causative agent of nonbacterial gastroenteritis. Reports of surveillance of NV in facilities that reported outbreaks are frequently found in publications, but reports of that in facilities without outbreaks are not found. We investigated the molecular epidemiology of NV isolates derived from asymptomatic food handlers working at a non-outbreak food catering facility in Hokkaido, Japan, from February to March in 2005 and January to February in 2006 by RNA polymerase gene sequencing. Approximately 12% (20/159) of the samples were positive for genogroup II (GII; 10.1% in 2005 and 14.2% in 2006). The GI genotypes were not detected. The data from the phylogenetic analysis indicated that, among the 20 strains detected, 13 strains were GII/genotype 2 (GII/2), two were GII/3, three were GII/8, and two were GII/12. GII/4, which has been found most frequently in recent outbreaks worldwide, including Japan, was not detected. We found that one individual was coinfected with two genotypes, GII/2 and GII/12. This is the first report of the detection of NV genotypes in asymptomatic food handlers working at a non-outbreak facility. The excretion of NV from healthy individuals may be an infection source of NV outbreaks as well as other food-borne diseases.

One-year monthly quantitative survey of noroviruses, enteroviruses, and adenoviruses in wastewater collected from six plants in Japan

Sewerage systems are important nodes to monitor human enteric pathogens transmitted via water. A quantitative virus survey was performed once a month for a year to understand the seasonal profiles of noroviruses genotype 1 and genotype 2, enteroviruses, and adenoviruses in sewerage systems. A total of 72 samples of influent, secondary-treated wastewater before chlorination and effluent were collected from six wastewater treatment plants in Japan. Viruses were successfully recovered from 100ml of influent and 1000ml of the secondary-treated wastewater and effluent using the acid rinse method. Viruses were determined by the RT-PCR or PCR method to obtain the most probable number for each sample. All the samples were also assayed for fecal coliforms (FCs) by a double-layer method. The seasonal profiles of noroviruses genotype 1 and genotype 2 in influent were very similar, i.e. they were abundant in winter (from November to March) at a geometric mean value of 190 and 200 RT-PCR units/ml, respectively, and less frequent in summer (from June to September), at 4.9 and 9.1 RT-PCR units/ml, respectively. The concentrations of enteroviruses and adenoviruses were mostly constant all the year round, 17 RT-PCR units/ml and 320 PCR units/ml in influent, and 0.044 RT-PCR units/ml and 7.0 PCR units/ml in effluent, respectively.

Intranasal administration of a recombinant adenovirus expressing the norovirus capsid protein stimulates specific humoral, mucosal, and cellular immune responses in mice

Norovirus (NV) is a major cause of acute, epidemic nonbacterial gastroenteritis in individuals of all ages. The immunological mechanism of NV infection and the approaches used to prevent infection remain to be elucidated. In this study, the specific immune responses of BALB/c mice were assessed following intranasal immunization with a recombinant adenovirus vector expressing the genogroup II4 (GGII/4) norovirus capsid protein. Analysis of IgM, IgG, and IgA antibodies specific for the recombinant virus-like particles (VLPs) of NV demonstrated that a high level of humoral immunity developed following immunization. Mucosal immune responses were also detectable in stool, intestinal homogenates, lung homogenates, and lung lavage samples. Specific cellular immune responses were observed in NV VLPs-restimulated splenocytes by ELISPOT and Th1/Th2 cytokine cytometric array (CBA). Serum IgG subclass analysis showed that a balanced Th1- and Th2-like cellular immune response was induced in BALB/c mice following immunization with recombinant adenovirus. These findings demonstrate that the intranasal immunization of a recombinant adenovirus expressing the NV capsid protein is an efficient strategy to stimulate systemic, mucosal, and cellular Th1/Th2 immune responses in mice, and could serve as a novel approach for designing NV vaccines.

Benign infantile convulsions associated with mild gastroenteritis: a retrospective study of 39 cases including virological tests and efficacy of anticonvulsants

Benign convulsions associated with mild gastroenteritis (CwG) are a commonly observed disorder in Asia, especially in infants and seniors. Here, we describe a retrospective study about the clinical features of CwG in 62 children hospitalized at St. Mary's Hospital (Kurume City, Japan) between January 1, 2000 and March 31, 2006, and further evaluate the efficacies of various anticonvulsant treatments for patients with CwG due to either rotavirus or norovirus. Causative diarrheal viruses were detected in 71% of the fecal specimens tested; 30 patients were positive for rotavirus, nine patients were positive for norovirus, two patients were positive for sapovirus, two patients were positive for adenovirus, and one patient was positive for coxackievirus A4. The age of onset for patients with norovirus-positive CwG (16.7+/-2.7 months) was significantly lower than that of patients with rotavirus-positive CwG (23.0+/-8.7 months). The duration of the seizures due to norovirus infection (11.8+/-12.0 h) was significantly longer than that due to rotavirus infection (4.9+/-5.7 h). There were no significant differences between the two groups with regard to the results of blood chemistry analysis, including the concentrations of serum electrolytes, blood glucose levels, and liver function tests. In this preliminary study, the duration of seizures in patients with CwG due to norovirus that was treated with carbamazepine was significantly shorter than the duration of seizures in the patients treated with another anticonvulsant (phenobarbital). Further randomized controlled studies are required to clarify the efficacies of the various anticonvulsants for patients with CwG.

Novel light-upon-extension real-time PCR assays for detection and quantification of genogroup I and II noroviruses in clinical specimens

Norovirus is now recognized as the leading cause of nonbacterial acute gastroenteritis in adults, causing numerous outbreaks worldwide. We have developed two novel light-upon-extension (LUX) real-time PCR assays for detection and quantification of norovirus genogroups I and II. The LUX system uses a fluorophore attached to one primer having a self-quenching hairpin structure, making it cost-effective and specific. The assays were evaluated against clinical stool specimens (n = 103) from Sweden and Nicaragua and compared to established methods. The norovirus assay detected more positive stool specimens (47/103) than conventional PCR (39/103) and corresponded to a TaqMan real-time PCR, with the exception of one specimen. Furthermore, the assays correctly identified all (n = 11) coded control specimens in a reference panel containing various genogroups and genotypes. Both LUX real-time PCR assays had a wide dynamic range, detecting from < or = 10(1) to 10(7) genes per reaction, resulting in a theoretical lower limit of < or = approximately 20,000 viruses per gram of stool. No cross-reactivity was noticed with specimens containing other enteric viruses, and by using melting curve analysis we could differentiate between norovirus genogroups I and II.

Norovirus infections in symptomatic and asymptomatic food handlers in Japan

Noroviruses are the leading cause of outbreaks of gastroenteritis in the world. At present, norovirus genogroup II, genotype 4 (GII/4), strains are the most prevalent in many countries. In this study we investigated 55 outbreaks and 35 sporadic cases of norovirus-associated gastroenteritis in food handlers in food-catering settings between 10 November 2005 and 9 December 2006 in Japan. Stool specimens were collected from both symptomatic and asymptomatic individuals and were examined for norovirus by real-time reverse transcription-PCR; the results were then confirmed by sequence analysis. Norovirus was detected in 449 of 2,376 (19%) specimens. Four genogroup I (GI) genotypes and 12 GII genotypes, including one new GII genotype, were detected. The GII/4 sequences were predominant, accounting for 19 of 55 (35%) outbreaks and 16 of 35 (46%) sporadic cases. Our results also showed that a large number of asymptomatic food handlers were infected with norovirus GII/4 strains. Norovirus GII had a slightly higher mean viral load (1 log unit higher) than norovirus GI, i.e., 3.81 x 10(8) versus 2.79 x 10(7) copies/g of stool. Among norovirus GI strains, GI/4 had the highest mean viral load, whereas among GII strains, GII/4 had the highest mean viral load (2.02 x 10(8) and 7.96 x 10(9) copies/g of stool, respectively). Importantly, we found that asymptomatic individuals had mean viral loads similar to those of symptomatic individuals, which may account for the increased number of infections and the predominance of an asymptomatic transmission route.