A norovirus outbreak at a long-term-care facility: the role of environmental surface contamination

Highly Effective Salt-Activated Alcohol-Based Disinfectants with Enhanced Antimicrobial Activity

Surfaces contaminated with pathogens raise concerns about the increased risk of disease transmission and infection. To clean biocontaminated surfaces, alcohol-based disinfectants have been predominantly used for disinfecting high-touch areas in diverse settings. However, due to its limited antimicrobial activities and concern over the emergence of alcohol-tolerant strains, much effort has been made to develop highly efficient disinfectant formulations. In this study, we hypothesize that the addition of a physical pathogen inactivation mechanism by salt recrystallization (besides the existing chemical inactivation mechanism by alcohol in such formulations) can improve inactivation efficiency by preventing the emergence of alcohol tolerance. To this end, we employed the drying-induced salt recrystallization process to implement the concept of highly efficient alcohol-based disinfectant formulations. To identify the individual and combined effects of isopropyl alcohol (IPA) and NaCl, time-dependent morphological/structural changes of various IPA solutions containing NaCl have been characterized by optical microscopy/X-ray diffraction analysis. Their antimicrobial activities have been tested on surfaces (glass slide, polystyrene Petri dish, and stainless steel) contaminated with Gram-positive/negative bacteria (methicillin-resistant Staphylococcus aureus, Pseudomonas aeruginosa, and Salmonella enterica subsp. enterica Typhimurium) and viruses (A/PR8/34 H1N1 influenza virus and HCoV-OC43 human coronavirus). We found that additional salt crystallization during the drying of the alcohol solution facilitated stronger biocidal effects than IPA-only formulations, regardless of the types of solid surfaces and pathogens, including alcohol-tolerant strains adapted from wild-type Escherichia coli MG1655. Our findings can be useful in developing highly effective disinfectant formulations by minimizing the use of toxic antimicrobial substances to improve public health and safety.

Occurrence of Human Viruses on Fomites in the Environment: A Systematic Review and Meta-analysis

Documenting the occurrence of viruses on fomites is crucial in determining the significance of fomite-mediated transmission and the potential use of fomites for environmental disease surveillance. We conducted a systematic review and meta-analysis to compile information on the occurrence of human viruses on fomites in the environment; we identified 134 peer-reviewed papers. We compiled sampling and measurement methods, results, quality control information, and whether virus data were compared with community health data from the papers. We conducted univariate and multivariate analyses to investigate if presence of virus on fomites was associated with virus type (enveloped, nonenveloped), sampling location (healthcare setting, nonhealthcare temporary setting, nonhealthcare nontemporary setting), and area of fomite swabbed (<50, 50-100, >100 cm2). Across 275 data sets from the 134 papers, there was the most data available for Coronaviridae and from fomites at hospitals. Positivity rates, defined as the percent positive fomite samples, were low (median = 6%). Data were available on viruses from 16 different viral families, but data on viruses from 9 families had few (n < 5) data sets. Many human virus families were not identified in this review (11 families). Less than 15% of the data sets reported virus concentrations in externally valid units (viruses per area of surface), and 16% provided a quantitative comparison between virus and health data. Virus type and area swabbed were significant predictors of virus presence on fomites, and the positivity rate of data sets collected from healthcare settings and nonhealthcare nontemporary settings (e.g., individual housing) were significantly higher than those collected in nonhealthcare temporary settings (e.g., restaurants). Data from this review indicates that viruses may be present on fomites, that fomite-mediated virus transmission may occur, and that fomites may provide information on circulation of infectious diseases in the community. However, more quantitative data on diverse viruses are needed, and method reporting needs significant improvements.

Evaluating the environmental microbiota across four National Health Service hospitals within England

Hospital surfaces contaminated with microbial soiling, such as dry surface biofilms (DSBs), can act as a reservoir for pathogenic micro-organisms, and inhibit their detection and removal during routine cleaning. Studies have recognized that such increases in bioburden can hinder the impact of disinfectants and mask the detection of potential pathogens. Cleanliness within healthcare settings is often determined through routine culture-based analysis, whereby surfaces that exhibit >2.5 colony-forming units (CFU) per cm² pose a risk to patient health; therefore, any underestimation could have detrimental effects. This study quantified microbial growth on high-touch surfaces in four hospitals in England over 19 months. This was achieved using environmental swabs to sample a variety of surfaces within close proximity of the patient, and plating these on to non-specific low nutrient detection agar. The presence of DSBs on surfaces physically removed from the environment was confirmed using real-time imaging through episcopic differential interference contrast microscopy combined with epifluorescence. Approximately two-thirds of surfaces tested exceeded the limit for cleanliness (median 2230 CFU/cm²), whilst 83% of surfaces imaged with BacLight LIVE/DEAD staining confirmed traces of biofilm. Differences in infection control methods, such as choice of surface disinfectants and cleaning personnel, were not reflected in the microbial variation observed and resulting risk to patients. This highlights a potential limitation in the effectiveness of the current standards for all hospital cleaning, and further development using representative clinical data is required to overcome this limitation.

Evaluation of the transmissibility of norovirus and the effectiveness of prevention and control measures for schools in Jiangsu Province

OBJECTIVE

This study aims to estimate the transmissibility of norovirus outbreaks in schools by different transmission routes, and to evaluate the effects of isolation, school-closure and disinfection measures under different intervention intensities, finally, scientific prevention and control suggestions are proposed.

METHOD

23 outbreaks of norovirus infectious diarrhea occurring in Jiangsu Province's school from 2012-2018 were selected and fitted to the model. The data includes various types of school places and pathogen genotype. A 'SEIAQRW' model with two transmission routes was established. The transmissibility of each outbreak was assessed using effective reproduction number, the efficacy of different intervention measures and intensities were evaluated by calculating the total attack rate and peak incidence.

RESULTS

The mean effective reproduction number of noroviruses was estimated to be 8.92 for the human-to-human route of transmission and 2.19 for the water or food-to-human route of transmission. When all symptomatic cases were isolated, the median peak incidence for both transmission routes both being less than 1.8%. There was a smaller reduction in total attack rate compared to peak incidence, the median total attack rate for the two transmission routes decreased by 17.59% and 42.09%, respectively. When the effect of school-closure or disinfection is more than 90%, the total attack rate and peak incidence in the human-to-human route are reduced by more than 90% compared to no intervention, and the peak incidence in the water or food-to-human routes can be reduced to less than 1.4%, but the reduction in the total attack rate is only 50% or so.

CONCLUSION

Norovirus outbreaks have a high rate of transmission in schools. In the case of norovirus outbreaks, isolation should be complemented by other interventions, and the implementation of high-intensity school closures or disinfection of the external environment can be effective in reducing the spread of the virus.

Norovirus attribution study: Detection of norovirus from the commercial food preparation environment in outbreak and non-outbreak premises

AIMS

Norovirus remains the most significant virological risk that is transmitted via food and the environment to cause acute gastroenteritis. This study aimed to investigate the hypothesis that the contamination of the commercial food production environment with norovirus will be higher in premises that have recently reported a foodborne norovirus outbreak than those that have not.

METHODS

Sampling of commercial food production environments was carried out across a 16-month period between January 2015 and April 2016 in the South East and the North West of England by local authority environmental health departments as part of routine surveillance visits to premises. A total of 2982 samples, 2038 virological and 944 bacteriological, were collected from 256 premises. Sixteen of these premises, six from South East and ten from North West England, were sampled as part of a public health outbreak investigation.

RESULTS & CONCLUSIONS

Overall, 2038 swabs were submitted for norovirus testing, with an average of eight swabs per premises (range 4 to 23) and a median of seven. Of the premises sampled, 11.7% (30/256) yielded at least one norovirus-positive sample (environmental, and/or food handler hand swab), and 2.5% of the swabs were positive for norovirus. A peak in the positivity rate was seen in the South East in April 2016. No associations were found between norovirus positivity and bacteriology indicators, or between bacteriology indicators and hygiene ratings.

SIGNIFICANCE AND IMPACT OF STUDY

This study demonstrates that food premises and food handlers remain a potential source of norovirus transmission and outbreaks.

Associations of infection control measures and norovirus outbreak outcomes in healthcare settings: a systematic review and meta-analysis

BACKGROUND

Although most norovirus outbreaks in high-income countries occur in healthcare facilities, information on associations between control measures and outbreak outcomes in these settings is lacking.

METHODS

We conducted a systematic review/meta-analysis to assess associations between norovirus outbreak control measures and outcomes in hospitals and long-term care facilities (LTCFs), globally. Using regression analyses stratified by setting (hospital/LTCF), we compared durations, attack rates, and case counts for outbreaks in which control measures were reportedly implemented to those in which they were not.

RESULTS

We identified 102 papers describing 162 norovirus outbreaks. Control measures were reportedly implemented in 118 (73%) outbreaks and were associated with 0.6 (95% CI: 0.3-1.1) times smaller patient case counts and 0.7 (95% CI: 0.4, 1.0) times shorter durations in hospitals but 1.5 (95% CI: 1.1-2.2), 1.5 (95% CI: 1.0-2.1) and 1.6 (95% CI: 1.0-2.6) times larger overall, resident and staff case counts, respectively, and 1.4 (95% CI: 1.0-2.0) times longer durations in LTCFs.

CONCLUSIONS

Reported implementation of control measures was associated with smaller/shorter outbreaks in hospitals but larger/longer outbreaks in LTCFs. Control measures were likely implemented in response to larger/longer outbreaks in LTCFs, rather than causing them. Prospective observational or intervention studies are needed to determine effectiveness.

Study of Risk Factors for Total Attack Rate and Transmission Dynamics of Norovirus Outbreaks, Jiangsu Province, China, From 2012 to 2018

Objective: To describe the epidemiological characteristics of norovirus outbreaks in Jiangsu Province, utilize the total attack rate (TAR) and transmissibility (R_unc) as the measurement indicators of the outbreak, and a statistical difference in risk factors associated with TAR and transmissibility was compared. Ultimately, this study aimed to provide scientific suggestions to develop the most appropriate prevention and control measures.

Method: We collected epidemiological data from investigation reports of all norovirus outbreaks in Jiangsu Province from 2012 to 2018 and performed epidemiological descriptions, sequenced the genes of the positive specimens collected that were eligible for sequencing, created a database and calculated the TAR, constructed SEIAR and SEIARW transmission dynamic models to calculate R_unc, and performed statistical analyses of risk factors associated with the TAR and R_unc.

Results: We collected a total of 206 reported outbreaks, of which 145 could be used to calculate transmissibility. The mean TAR in was 2.6% and the mean R_unc was 12.2. The epidemiological characteristics of norovirus outbreaks showed an overall increasing trend in the number of norovirus outbreaks from 2012 to 2018; more outbreaks in southern Jiangsu than northern Jiangsu; more outbreaks in urban areas than in rural areas; outbreaks occurred mostly in autumn and winter. Most of the sites where outbreaks occurred were schools, especially primary schools. Interpersonal transmission accounted for the majority. Analysis of the genotypes of noroviruses revealed that the major genotypes of the viruses changed every 3 years, with the GII.2 [P16] type of norovirus dominating from 2016 to 2018. Statistical analysis of TAR associated with risk factors found statistical differences in all risk factors, including time (year, month, season), location (geographic location, type of settlement, type of premises), population (total number of susceptible people at the outbreak site), transmission route, and genotype (P < 0.05). Statistical analysis of transmissibility associated with risk factors revealed that only transmissibility was statistically different between sites.

Conclusions: The number of norovirus outbreaks in Jiangsu Province continues to increase during the follow-up period. Our findings highlight the impact of different factors on norovirus outbreaks and identify the key points of prevention and control in Jiangsu Province.

Microbial contamination of hands with or without the use of bidet toilets (electric toilet seats with water spray) after defecation

Bidet toilets (electric toilet seats with water spray) are increasing in popularity worldwide. However, the extent of reduction of microbial contamination of the hands with the use of bidet toilets after defecation is unclear. Microbe contamination of the hands with and without the use of bidet toilets after defecation was examined in 32 nursing students. Double gloves were worn on the dominant hand and four layers of toilet paper were used to wipe the buttocks after defecation, and microbe contamination of the second glove (outer glove) of the double gloves was examined. The volunteers were free to select the flow volume, wash time of the bidet, and the type of bidet. Without the use of a bidet toilet, the average value ± standard deviation of the number of microbes attached to the gloves was 39,499.3 ± 77,768.3 colony forming units (cfu)/glove; however, it was 4,146.9 ± 11,427.7 cfu/glove when the bidet toilet was used. The number of microbes adhering to gloves was significantly reduced when a bidet toilet was used (p < 0.00001, Wilcoxon signed-rank test).

Quantitative microbial risk assessment of human norovirus infection in environmental service workers due to healthcare-associated fomites

BACKGROUND

Healthcare-associated norovirus outbreaks place a large burden on healthcare staff. Environmental service workers (ESWs), however, remain understudied despite high contact with potentially contaminated surfaces. Understanding the magnitude of the risk of norovirus infection in healthcare ESWs can protect workers and improve infection control.

AIM

This study simulated the risk of norovirus infection for unprotected ESWs after a single fomite contact, assuming no disinfection or protective equipment, in norovirus-positive patient rooms. In addition, the risk of secondary surface transmission from norovirus-exposed ESWs was simulated.

METHODS

A quantitative microbial risk assessment employing two-dimensional Monte Carlo simulation with parameters extracted from the literature was used to estimate norovirus infection from multiple fomite contact scenarios defined by: norovirus source (patient vomit/diarrhoea), location (bathroom/patient room) and target outcome (ESW/secondary illness).

FINDINGS

Unprotected ESWs have a maximum estimated risk of norovirus infection of 33% (1:3) for a single fomite contact in a room where a norovirus-positive patient had a diarrhoeal event. Patient vomit events lead to fomite contact risk estimates that are four orders of magnitude lower than those for diarrhoeal events. The estimated risk of secondary illness from touching a common surface is as high as 25% (1:4) after single fomite exposure following a diarrhoeal event.

CONCLUSIONS

A single fomite contact may lead to sizable risk of norovirus infection in ESWs if personal protective equipment and disinfection are not used appropriately. ESWs can also transfer virus to secondary surfaces, initiating further infections. Interventions are needed to reduce fomite transfer of norovirus, and protect patients and staff from nosocomial infections.

Antimicrobial coatings for environmental surfaces in hospitals: a potential new pillar for prevention strategies in hygiene

Recent reports provide evidence that contaminated healthcare environments represent major sources for the acquisition and transmission of pathogens. Antimicrobial coatings (AMC) may permanently and autonomously reduce the contamination of such environmental surfaces complementing standard hygiene procedures. This review provides an overview of the current status of AMC and the demands to enable a rational application of AMC in health care settings. Firstly, a suitable laboratory test norm is required that adequately quantifies the efficacy of AMC. In particular, the frequently used wet testing (e.g. ISO 22196) must be replaced by testing under realistic, dry surface conditions. Secondly, field studies should be mandatory to provide evidence for antimicrobial efficacy under real-life conditions. The antimicrobial efficacy should be correlated to the rate of nosocomial transmission at least. Thirdly, the respective AMC technology should not add additional bacterial resistance development induced by the biocidal agents and co- or cross-resistance with antibiotic substances. Lastly, the biocidal substances used in AMC should be safe for humans and the environment. These measures should help to achieve a broader acceptance for AMC in healthcare settings and beyond. Technologies like the photodynamic approach already fulfil most of these AMC requirements.

Public Buses Decontamination by Automated Hydrogen Peroxide Aerosolization System

BACKGROUND: Public transportation has been linked to an increase in the risk of coronavirus disease 2019 transmission. The effective decontamination system using aerosolized hydrogen peroxide can mitigate the transmission risk from using public transportation. AIM: The aim of this study was to develop and validate an effective decontamination system for public transport. METHODS: The experimental research was performed in 13 inter-city public buses. The aerosol generator with ultrasonic atomizer was used in the experiment. The validation process for disinfection was conducted using both a chemical indicator (CI) and spore discs biological indicator (inoculated with 106 Geobacillus stearothermophilus enclosed in glassine envelopes). The CIs and biological indicators were marked by number and placed in nine locations on each bus. The decontamination cycle was developed by analyzed of various aerosolized and decomposition period. Both concentrations of hydrogen peroxide, 5% and 7%, were used for comparison. RESULTS: In an aerosolized period, both concentrations of hydrogen peroxide at 30 min were effective for sporicidal 6-log reductions. The decontamination cycle totaled 100 min, based on a 70 min average decomposition time. CONCLUSIONS: The automated hydrogen peroxide aerosolized system is a highly effective and safe method of decontaminating public buses.

Less severe clinical symptoms of Norwalk virus 8fIIb inoculum compared to its precursor 8fIIa from human challenge studies

Noroviruses (NoV) are a leading cause of epidemic gastroenteritis. Human challenge studies have been used to examine the infectivity, pathogenicity, and host immune response to NoV as well as vaccine efficacy. The goal of this study was to conduct a meta-analysis of data from five previously completed human challenge trials and compare the response to the secondary NV inoculum (8fIIb) to its precursor (8fIIa). We investigated a total of 158 subjects: 76 subjects were experimentally challenged with NV inoculum 8fIIa, and 82 subjects were challenged with 8fIIb. We compared demographic characteristics, infection, illness, mean severity score, blood types, and duration of viral shedding between the two groups of subjects. There were no statistically significant differences in overall infection and illness rates between subjects inoculated with 8fIIa and 8fIIb. However, individuals challenged with 8fIIa had significantly higher severity scores (5.05 vs. 3.22, p = .008) compared with those challenged with 8fIIb. We also observed that infection with 8fIIb was associated with significantly longer duration of viral shedding compared with 8fIIa (11.0 days vs. 5.0 days, p = .0005). These results have serious implications for the development of new NoV inocula for human challenge studies to test candidate vaccine efficacy-where illness severity and duration of viral shedding are important outcomes.

Usos y limitaciones de la lámpara ultravioleta germicida portátil para la desinfección de superficies

RESUMENLa morbimortalidad causada por infecciones vinculadas a la atención sanatoria ha llevado a cuestionar si los métodos de desinfección convencionales son inadecuados y se requieren métodos complementarios, como la fumigación de la habitación y la irradiación ultravioleta. Ello ha dado lugar a la preocupación por que estos métodos alternativos puedan poner en riesgo al personal sanitario y a los pacientes.Objetivos. (1) Determinar la eficacia de la lámpara ultravioleta C germicida portátil para la desinfección de superficies, (2) evaluar el cambio de la humedad relativa (HR) y las distintas distancias específicas en las tasas de letalidad bacteriana, y (3) evaluar los posibles problemas a que conlleva la exposición.Métodos. En el presente estudio se investiga si una lámpara germicida portátil puede desinfectar de forma eficaz superficies tratadas con esporulación o germinación bacteriana y se evalúa el efecto de condiciones ambientales cambiantes, como la humedad relativa (HR), la posición y las distancias específicas, en las tasas de letalidad germicida.Resultados. Se constató una mejor tasa de letalidad con una HR de 40-65% y en un rango de temperatura de 21-24°C. Tanto la HR alta como la HR baja interfirieron con la capacidad de la radiación UV-C para inactivar la germinación microbiana. En el caso de la esporulación bacteriana, el aumento del secado de la superficie fue el factor de mayor importancia para aumentar la tasa de letalidad.Conclusiones. En esta investigación se demostró la eficacia de la radiación UV-C bajo condiciones óptimas, irradiación directa y una distancia específica corta (12.7 cm). Sin embargo, cuando es utilizada en condiciones que no son óptimas existen limitaciones. El aumento de la distancia y los ángulos de irradiación indirecta resultaron en tasas de letalidad más bajas. Cabe señalar que durante su uso es importante minimizar la exposición innecesaria de pacientes y personal sanitario.

Involvement of Workers in Closed and Semiclosed Institutions in Outbreaks of Acute Gastroenteritis Due to Norovirus

Norovirus outbreaks frequently occur in closed or semiclosed institutions. Recent studies in Catalonia and various countries indicate that, during outbreaks in these institutions, norovirus is detected in between 23% and 60% of workers, and the prevalence of infection in asymptomatic workers involved in outbreaks ranges from 17% to 40%. In this work, we carried out a prospective study to investigate the involvement of workers in closed and semiclosed institutions during outbreaks. The attack rates (ARs) and the rate ratios (RRs) were calculated according to the type of transmission and occupational category. The RRs and 95% confidence intervals (CIs) between workers and users were calculated. The mean cycle of quantification (Cq) values were compared according to the genogroup and the presence of symptoms. ARs were higher in person-to-person transmission than in common vehicle outbreaks, and 38.8% of workers were symptomatic. The RR between workers and users was 0.46 (95% CI 0.41-0.52). The ARs in workers were high, particularly in workers with closer contact with users. The mean Cq was lower in patients than in asymptomatic infected persons, although the difference was only significant for genogroup I (GI). The frequency of asymptomatic infected persons suggests that personal hygiene measures should be followed by all workers in the centers affected.

Inactivation of hepatitis A virus and murine norovirus on surfaces of plastic, steel and raspberries using steam-ultrasound treatment

The leading causes of foodborne viral disease outbreaks are human norovirus and hepatitis A virus (HAV). Their environmental persistence enables contamination of kitchen surfaces and crops often consumed raw, such as berries. Many decontamination procedures are inefficient and unsuitable for surfaces of industrial kitchen environments and soft fruits. In this study, we investigated the efficiency of a novel surface decontamination technology, combining steam and ultrasound (steam-ultrasound). Plastic, steel or raspberry surfaces were spiked with the norovirus surrogate, murine norovirus (MNV), and HAV, and steam-ultrasound treated at 85, 90 and 95 °C for 0-5 s. Post treatment viruses were titrated for survival by plaque assay and for genome stability by real-time quantitative PCR (RT-qPCR) of nucleic acid extracts. Survival of viruses were estimated in a log-linear model and the treatment time requirements for each decimal reduction (D value) in viral survival were calculated. The estimated D values of MNV or HAV were 0.4-0.2 or 1.1-0.8 s on plastic, 0.9-0.7 or 1.4-0.8 s on steel and 1.6-1.7 or 3.2-4.7 s on raspberries. No clear trend of genome reduction was observed with tested treatment parameters. Raspberries treated up to 4 s retained its natural texture and visual appeal similar to untreated controls whilst monitored for 7 days. In conclusion, steam-ultrasound treatment can within seconds reduce the titre of foodborne viruses on surfaces of plastic, steel and raspberries. This may particularly benefit industrial scale production of soft fruits for raw consumption and for swift non-hazardous decontamination of industrial kitchen surfaces.

Solid Oxygen-Purifying (SOP) Filters: A Self-Disinfecting Filters to Inactivate Aerosolized Viruses

Normal heating, ventilation, and air conditioning (HVAC) systems typically use high-efficiency particulate air (HEPA) filters, which can filter dust, various pollutants, and even bacteria and viruses from indoor air. However, since HEPA filters cannot not clean themselves and due to the nature of these microbes which can survive for long periods of time, changing these filters improperly could transmit pathogenic bacteria or viruses, and could even lead to new infections. This study indicated that these manufactured Solid Oxygen-purifying (SOP) filters have the potential to self-disinfect, filter, and inactivate aerosolized viruses. MS2 bacteriophage was used as a model virus in two different experiments. The first experiment involved aerosolization of the virus, while the second were a higher viral load using a soaking method. The SOP filters inactivated up to 99.8% of the virus particles in both experiments, provided that the density of the SOP filter was high. Thus, SOP filters could self-clean, which led to protection against airborne and aerosolized viruses by inactivating them on contact. Furthermore, SOP filters could be potentially use or addition in HVAC systems and face masks to prevent the transmission of airborne and aerosolized viruses.

Natural Host-Environmental Media-Human: A New Potential Pathway of COVID-19 Outbreak

Identifying the first infected case (patient zero) is key in tracing the origin of a virus; however, doing so is extremely challenging. Patient zero for coronavirus disease 2019 (COVID-19) is likely to be permanently unknown. Here, we propose a new viral transmission route by focusing on the environmental media containing viruses of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) or RaTG3-related bat-borne coronavirus (Bat-CoV), which we term the "environmental quasi-host." We reason that the environmental quasi-host is likely to be a key node in helping recognize the origin of SARS-CoV-2; thus, SARS-CoV-2 might be transmitted along the route of natural host-environmental media-human. Reflecting upon viral outbreaks in the history of humanity, we realize that many epidemic events are caused by direct contact between humans and environmental media containing infectious viruses. Indeed, contacts between humans and environmental quasi-hosts are greatly increasing as the space of human activity incrementally overlaps with animals' living spaces, due to the rapid development and population growth of human society. Moreover, viruses can survive for a long time in environmental media. Therefore, we propose a new potential mechanism to trace the origin of the COVID-19 outbreak.

Survival and inactivation of human norovirus GII.4 Sydney on commonly touched airplane cabin surfaces

Human norovirus (HuNoV) is one of the leading causes of acute gastroenteritis globally. HuNoV outbreaks have been recently reported during air travels. Contaminated surfaces are known as a critical transmission route at various settings. The aim of this study was to provide key information about the survival and the decontamination of HuNoV on three commonly touched airplane cabin surfaces. In this study, we monitored the survival of HuNoV on seat leather, plastic tray table, and seatbelt for 30 days, with and without additional organic load (simulated gastric fluid). The efficacy of two EPA registered anti-norovirus disinfectants were also evaluated. Results showed that HuNoV was detected at high titers (>4 log₁₀ genomic copy number) for up to 30 days when additional organic load was present. Both tested disinfectants were found highly ineffective against HuNoV when the surface was soiled. The study showed that when the organic load was present, HuNoV was highly stable and resistant against disinfectants. Findings from this study indicated that appropriate procedures should be developed by airline companies with the help of public health authorities to decrease passengers' exposure risk to HuNoV.

The burden of gastroenteritis outbreaks in long-term care settings in Philadelphia, 2009-2018

OBJECTIVE

Gastroenteritis causes significant morbidity and mortality in long-term care facility (LTCF) residents, a growing population within the United States. We set out to better understand gastroenteritis outbreaks in LTCF by identifying outbreak and facility characteristics associated with outbreak incidence as well as outbreak duration and size.

DESIGN

We conducted a retrospective cross-sectional study on LTCFs in Philadelphia County from 2009 to 2018. Outbreak characteristics and interventions were extracted from Philadelphia Department of Public Health (PDPH) database and quality data on all LTCFs was extracted from Centers for Medicare and Medicaid Services Nursing Home Compare database.

RESULTS

We identified 121 gastroenteritis outbreaks in 49 facilities. Numbers of affected patients ranged from 2 to 211 patients (median patient illness rate, 17%). Staff were reported ill in 94 outbreaks (median staff illness rate, 5%). Outbreak facilities were associated with higher occupancy rates (91% vs 88%; P = .033) and total bed numbers (176 vs 122; P = .071) compared to nonoutbreak facilities. Higher rates of staff illness were associated with prolonged outbreaks (13% vs 4%; P < .001) and higher patient illness rates (9% vs 4%; P = .012). Prolonged outbreaks were associated with lower frequency of cohorting for outbreak management (13% vs 41%; P = .046).

CONCLUSION

This study is the largest published analysis of gastroenteritis outbreaks in LTCFs. Facility characteristics and staff disease activity were associated with more severe outbreaks. Heightened surveillance for gastrointestinal symptoms among staff and increased use of cohorting might reduce the risk of prolonged gastroenteritis outbreaks in LTCF.

Norovirus in health care and implications for the immunocompromised host

PURPOSE OF REVIEW

The majority of norovirus outbreaks in the United States occur in healthcare facilities. With the growing population of immunocompromised hosts who are in frequent contact with healthcare facilities, norovirus is not only a threat to hospitals and nursing homes but also to these individuals. This review summarizes the impact of norovirus infection on healthcare facilities and immunocompromised hosts.

RECENT FINDINGS

The natural history of norovirus infection in immunocompromised individuals remains poorly understood. Although host immune responses play a critical role in reducing duration of viral shedding and viral load in norovirus-infected individuals, why some immunocompromised patients spontaneously recover while others develop a chronic and protracted course of illness remains unclear. Norovirus outbreaks occur in healthcare facilities because the virus is highly contagious, resistant to disinfection and efficiently transmitted. The use of real-time metagenomic next-generation sequencing and phylogenetic analyses has provided valuable information on transmission patterns in complex hospital-associated norovirus outbreaks. The development of human intestinal enteroid cultures enables the determination of effectiveness of disinfectants against human noroviruses, circumventing the validity questions with surrogate virus models due to differences in susceptibility to inactivation and disinfectants.

SUMMARY

Metagenomics next-generation sequencing can enhance our understanding of norovirus transmission and lead to more timely mitigation strategies to curb norovirus outbreaks in healthcare facilities. With new in-vitro cultivation methods for human noroviruses, candidate vaccines and effective antivirals could be available in the near future.

A foodborne norovirus outbreak in a nursing home and spread to staff and their household contacts

On 16 March 2018, a nursing home notified a possible acute gastroenteritis outbreak that affected 11 people. Descriptive and case-control studies and analysis of clinical and environmental samples were carried out to determine the characteristics of the outbreak, its aetiology, the transmission mechanism and the causal food. The extent of the outbreak in and outside the nursing home was determined and the staff factors influencing propagation were studied by multivariate analysis. A turkey dinner on March 14 was associated with the outbreak (OR 4.22, 95% CI 1.11-16.01). Norovirus genogroups I and II were identified in stool samples. The attack rates in residents, staff and household contacts of staff were 23.49%, 46.22% and 22.87%, respectively. Care assistants and cleaning staff were the staff most frequently affected. Cohabitation with an affected care assistant was the most important factor in the occurrence of cases in the home (adjusted OR 6.37, 95% CI 1.13-36.02). Our results show that staff in close contact with residents and their household contacts had a higher risk of infection during the norovirus outbreak.

Norovirus detection in environmental samples in norovirus outbreaks in closed and semi-closed settings

BACKGROUND

Environmental surfaces are a potential vehicle for the transmission of norovirus outbreaks in closed and semi-closed settings. Testing of environmental samples may help control outbreaks.

AIM

To assess the level of environmental contamination by norovirus in acute gastroenteritis outbreaks in closed or semi-closed settings (nursing homes, schools, kindergartens, youth accommodations, hospitals and social health centres) in the Barcelona region between January 2017 and March 2019.

METHODS

A prospective surveillance study was carried out. Environmental samples (529) were collected in 46 of the 50 outbreaks of acute norovirus gastroenteritis from environmental surfaces of common areas, bathrooms and kitchens in closed and semi-closed settings when the outbreak was notified and 10 days later. Instructions for taking environmental samples were distributed to public health inspectors. Norovirus was detected by reverse transcription polymerase chain reaction.

FINDINGS

Environmental samples were positive for norovirus in 31 (67.4%) outbreaks. Norovirus was most frequently detected on elevator buttons (4/17, 24%), toilet handles (16/66, 24%) and handrail bars (7/34, 21%). Positive samples from the first sampling were mainly found in bathrooms and greater viral persistence in the second sampling was found on elevator buttons and TV remote controls. Nursing homes were the setting with the most types of environmental surfaces contaminated (82% in first samples and 55% in second samples).

CONCLUSION

The probability of virus detection is independent of the time between notification of the outbreak or symptom onset and sample collection. Our results suggest possible defects in cleaning protocols and disinfection in closed and semi-closed settings.

Seasonal dynamics of DNA and RNA viral bioaerosol communities in a daycare center

BACKGROUND

Viruses play an important role in ecosystems, including the built environment (BE). While numerous studies have characterized bacterial and fungal microbiomes in the BE, few have focused on the viral microbiome (virome). Longitudinal microbiome studies provide insight into the stability and dynamics of microbial communities; however, few such studies exist for the microbiome of the BE, and most have focused on bacteria. Here, we present a longitudinal, metagenomic-based analysis of the airborne DNA and RNA virome of a children's daycare center. Specifically, we investigate how the airborne virome varies as a function of season and human occupancy, and we identify possible sources of the viruses and their hosts, mainly humans, animals, plants, and insects.

RESULTS

Season strongly influenced the airborne viral community composition, and a single sample collected when the daycare center was unoccupied suggested that occupancy also influenced the community. The pattern of influence differed between DNA and RNA viromes. Human-associated viruses were much more diverse and dominant in the winter, while the summertime virome contained a high relative proportion and diversity of plant-associated viruses.

CONCLUSIONS

This airborne microbiome in this building exhibited seasonality in its viral community but not its bacterial community. Human occupancy influenced both types of communities. By adding new data about the viral microbiome to complement burgeoning information about the bacterial and fungal microbiomes, this study contributes to a more complete understanding of the airborne microbiome.

A simple and short microbiology practical improves undergraduate nursing students' awareness of bacterial traits and ability to avoid spreading infections

BACKGROUND

Nurses are responsible for implementing appropriate measures to reduce hospital infections, especially with multidrug resistant bacteria, so nursing students should learn about microbiology. This helps them to understand bacterial dissemination and infectious disease control. Because of tight schedules, however, its teaching is limited in undergraduate nursing classes in Japan. We therefore tested whether a simple short practical session in a microbiology class could help to improve undergraduate nursing students' awareness of bacterial traits and how to prevent infections.

METHODS

This study involved second-grade nursing students (n = 76). Two short practical sessions (a total of 3 h, across 2 days) were used to assess the effectiveness of washing or disinfection on hand bacteria in a 16-class microbiology course (total class time was 24 h, plus an exam). Hand bacteria were sampled on LB agar plates with orientation during the first half-day, and the plates examined for colonies with distinct color or morphological traits, and discussed, in the second session, a week later. Questionnaires before and after the exercise were used to assess changes in awareness of unseen bacteria inhabiting around us connecting bacterial traits and how to prevent infections.

RESULTS

The results showed that the practical increased the nursing students' awareness of fomites (utensils) (p = 0.0115), fomites (contact-based) (p = 0.0016), habitats (body surface) (p = 0.0127), action facilitating hospital infection (p = 0.0166), and changes in physical condition caused by bacterial infections (p = 0.0136). There were no changes in word associations (p = 0.627) or habitats (inside body) (p = 0.308). Difficulty score, which is an element in questionnaire psychometric properties, tended to be close to the expected score through the practical, but not statistical significant. In addition, regardless of before or after practical, Cronbach α score, which is an indicator of the reliability among items of multi-choice questions, showed > 0.8, indicating validity of evaluation items. Thus, the student's awareness of unseen bacteria inhabiting around us was significantly increased as compared to those before practical in microbiology class.

CONCLUSIONS

The simple short practical effectively improved nursing students' awareness of unseen bacteria inhabiting around us in microbiology course, useful for even tight teaching schedules.

Modeling the role of fomites in a norovirus outbreak

Norovirus accounts for a large portion of the gastroenteritis disease burden, and outbreaks have occurred in a wide variety of environments. Understanding the role of fomites in norovirus transmission will inform behavioral interventions, such as hand washing and surface disinfection. The purpose of this study was to estimate the contribution of fomite-mediated exposures to infection and illness risks in outbreaks. A simulation model in discrete time that accounted for hand-to-porous surfaces, hand-to-nonporous surfaces, hand-to-mouth, -eyes, -nose, and hand washing events was used to predict 17 hr of simulated human behavior. Norovirus concentrations originated from monitoring contamination levels on surfaces during an outbreak on houseboats. To predict infection risk, two dose-response models (fractional Poisson and ₂F₁ hypergeometric) were used to capture a range of infection risks. A triangular distribution describing the conditional probability of illness given an infection was multiplied by modeled infection risks to estimate illness risks. Infection risks ranged from 70.22% to 72.20% and illness risks ranged from 21.29% to 70.36%. A sensitivity analysis revealed that the number of hand-to-mouth contacts and the number of hand washing events had strong relationships with model-predicted doses. Predicted illness risks overlapped with leisure setting and environmental attack rates reported in the literature. In the outbreak associated with the viral concentrations used in this study, attack rates ranged from 50% to 86%. This model suggests that fomites may have accounted for 25% to 82% of illnesses in this outbreak. Fomite-mediated exposures may contribute to a large portion of total attack rates in outbreaks involving multiple transmission modes. The findings of this study reinforce the importance of frequent fomite cleaning and hand washing, especially when ill persons are present.

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.

Foodborne and Food-Handler Norovirus Outbreaks: A Systematic Review

Norovirus (NoV) is the commonest cause of gastrointestinal disease in the United Kingdom and in many developed countries, causing diarrhea and vomiting in millions of cases worldwide annually. Transmission is most often mediated from person to person. NoV infection has, however, additionally been associated with the consumption of food, either through the consumption of food contaminated at source such as seafood, berries, and salad, or as a consequence of the foodstuff being contaminated in some way by a food handler during processing or serving. A systematic review of outbreaks attributed to NoV between January 2003 and July 2017 was conducted to assess the contribution of food handlers to the burden of NoV, and to identify foods commonly associated with NoV outbreaks. A total of 3021 articles were screened, of which 27 met the definition of confirmed foodborne outbreaks and 47 met the criteria for definite food-handler NoV outbreaks. Of all food types, shellfish were implicated in the greatest number of definite foodborne outbreaks. Food handlers contributed to definite food-handler outbreaks involving a diverse range of foodstuffs and in a wide variety of settings, including weddings and military establishments. More genotypes of NoV were found in people who were ill than in samples from food and food handlers. The potential for both food products and food handlers to contribute to the burden of NoV infection is demonstrated conclusively.

Prevalence of Human Noroviruses in Commercial Food Establishment Bathrooms

Although transmission of human norovirus in food establishments is commonly attributed to consumption of contaminated food, transmission via contaminated environmental surfaces, such as those in bathrooms, may also play a role. Our aim was to determine the prevalence of human norovirus on bathroom surfaces in commercial food establishments in New Jersey, Ohio, and South Carolina under nonoutbreak conditions and to determine characteristics associated with the presence of human norovirus. Food establishments (751) were randomly selected from nine counties in each state. Four surfaces (underside of toilet seat, flush handle of toilet, inner door handle of stall or outer door, and sink faucet handle) were swabbed in male and female bathrooms using premoistened macrofoam swabs. A checklist was used to collect information about the characteristics, materials, and mechanisms of objects in bathrooms. In total, 61 (1.5%) of 4,163 swabs tested were presumptively positive for human norovirus, 9 of which were confirmed by sequencing. Some factors associated with the presence of human norovirus included being from South Carolina (odd ratio [OR], 2.4; 95% confidence interval [CI], 1.2 to 4.9; P < 0.05) or New Jersey (OR, 1.7; 95% CI, 0.9 to 3.3; 0.05 < P < 0.10), being a chain establishment (OR, 1.9; 95% CI, 1.1 to 3.3; P < 0.05), being a unisex bathroom (versus male: OR, 2.0; 95% CI, 0.9 to 4.1; 0.05 < P < 0.10; versus female: OR, 2.6; 95% CI, 1.2 to 5.7; P < 0.05), having a touchless outer door handle (OR, 3.3; 95% CI, 0.79 to 13.63; 0.05 < P < 0.10), and having an automatic flush toilet (OR, 2.5, 95% CI, 1.1 to 5.3; 0.05 < P < 0.10). Our findings confirm that the presence of human norovirus on bathroom surfaces in commercial food establishments under nonoutbreak conditions is a rare event. Therefore, routine environmental monitoring for human norovirus contamination during nonoutbreak periods is not an efficient method of monitoring norovirus infection risk.

Routes of transmission of influenza A H1N1, SARS CoV, and norovirus in air cabin: Comparative analyses

Identifying the exact transmission route(s) of infectious diseases in indoor environments is a crucial step in developing effective intervention strategies. In this study, we proposed a comparative analysis approach and built a model to simulate outbreaks of 3 different in-flight infections in a similar cabin environment, that is, influenza A H1N1, severe acute respiratory syndrome (SARS) coronavirus (CoV), and norovirus. The simulation results seemed to suggest that the close contact route was probably the most significant route (contributes 70%, 95% confidence interval [CI]: 67%-72%) in the in-flight transmission of influenza A H1N1 transmission; as a result, passengers within 2 rows of the index case had a significantly higher infection risk than others in the outbreak (relative risk [RR]: 13.4, 95% CI: 1.5-121.2, P = .019). For SARS CoV, the airborne, close contact, and fomite routes contributed 21% (95% CI: 19%-23%), 29% (95% CI: 27%-31%), and 50% (95% CI: 48%-53%), respectively. For norovirus, the simulation results suggested that the fomite route played the dominant role (contributes 85%, 95% CI: 83%-87%) in most cases; as a result, passengers in aisle seats had a significantly higher infection risk than others (RR: 9.5, 95% CI: 1.2-77.4, P = .022). This work highlighted a method for using observed outbreak data to analyze the roles of different infection transmission routes.

The Role of Environmental Contamination in the Transmission of Nosocomial Pathogens and Healthcare-Associated Infections

PURPOSE OF REVIEW

The aim of this review is to highlight the role of environmental contamination in healthcare-associated infections (HAIs) and to discuss the most commonly implicated nosocomial pathogens.

RECENT FINDINGS

Recent studies suggest that environmental contamination plays a significant role in HAIs and in the unrecognized transmission of nosocomial pathogens during outbreaks, as well as ongoing sporadic transmission. Several pathogens can persist in the environment for extended periods and serve as vehicles of transmission and dissemination in the hospital setting. Cross-transmission of these pathogens can occur via hands of healthcare workers, who become contaminated directly from patient contact or indirectly by touching contaminated environmental surfaces. Less commonly, a patient could become colonized by direct contact with a contaminated environmental surface. This review describes the role of environmental contamination in HAIs and provides context for reinforcing the importance of hand hygiene and environmental decontamination for the prevention and control of HAIs.

The Use of Electric Toilet Seats with Water Spray Is Efficacious in Maintaining Hand Hygiene in Experimental Model

A simulation experiment was conducted to examine hand contamination from wiping the buttocks after the use and non-use of an electric toilet seat with water spray. A model of the buttocks was smeared with artificial diarrheal feces containing Serratia marcescens, and wiped by the participants wearing disposable gloves with 4 sheets of toilet paper after the use and non-use of the water spray of an electric toilet seat. Subsequently, the presence of S. marcescens on the surface of the gloves was quantified. After using the water spray, the mean count±standard deviation of S. marcescens was 0.067±0.249 colony-forming units (cfu)/glove, and it was 4,275±6,069 cfu/glove when water spray was not used. The cfu of S. marcescens was significantly lower when the water spray was used (p<0.00001) prior to wiping the artificial diarrheal feces. This result supports the effectiveness of water spray to prevent defecation-related hand contamination.

The uses and limitations of a hand-held germicidal ultraviolet wand for surface disinfection

The morbidity and mortality from healthcare associated infections has raised concern that conventional disinfection methods are inadequate and that other adjunct methods such as room fumigation and ultraviolet irradiation may be needed. There is also concern that these alternative methods may pose a risk to workers and patients.

OBJECTIVES

(1) Determine the efficacy of a germicidal UV-C wand for surface disinfection, (2) evaluate changing relative humidity (RH) and different target distances on bacteria kill rates, and (3) assess potential exposure concerns.

METHODS

This study investigates whether a hand-held germicidal wand can efficaciously disinfect surfaces treated with either a vegetative or spore forming bacterium and to evaluate the effect of changing environmental conditions such as relative humidity (RH), target position, and target distances on microbial kill rates.

RESULTS

Kill rate was best at 40-65% RH at a temperature range of 21-24°C. Both high and low RH interfered with the ability of UV-C to kill the vegetative microbe. In the case of the spore forming bacterium, increased surface drying time was the most significant factor increasing kill rate.

CONCLUSIONS

This research demonstrates that UV-C was efficacious under optimal conditions, a direct beam exposure, and a short target distance (12.7 cm). However, there are limitations when used in non-optimal conditions. Increased distance and indirect beam angles resulted in lower kill rates. It is also important to minimize unnecessary patient and worker exposure during its use.

Norovirus Infections in Long-Term Care Facilities

Noroviruses have emerged as one of the leading causes of viral gastroenteritis worldwide, affecting community-dwelling and institutionalized older adults. Recent global epidemics present a growing challenge to the healthcare system and to long-term care facilities. Noroviruses spread readily and rapidly through multiple routes (e.g., person-to-person contact, contact with contaminated surfaces, airborne dissemination of vomitus) and thus are able to sustain an epidemic efficiently and successfully. Although norovirus gastroenteritis is a short self-limited illness in healthy immunocompetent individuals, it can result in significant morbidity and mortality in vulnerable compromised persons such as frail elderly persons and older residents of nursing homes. Diagnosis is made by clinical assessment and confirmed primarily by stool evaluation using polymerase chain reaction. Treatment is confined to supportive measures. Public health prevention and control strategies provide guidance regarding surveillance and the necessary steps to curb the clinical effect and spread of norovirus infections in various settings, including long-term care.

Resistance of Enteric Viruses on Fomites

Human enteric viruses are associated with several clinical features, especially gastroenteritis. Large amounts of these viruses can be released in the environment and spread to people. Enteric viruses are nonenveloped viruses and have displayed good survival in the environment. They can be significantly resistant in food and water but also on fomites, and this is thought to play a role in transmission, leading to sporadic cases or outbreaks. The survival of enteric viruses on fomites relies on many factors including the virus itself, fomite properties, and extrinsic environmental factors such as temperature or relative humidity. Several reports in the literature have found an association with gastroenteritis cases or outbreaks and fomites naturally contaminated by enteric viruses. However, the study of virus survival following natural contamination is challenging, and most published studies are laboratory based, using experimental contamination. In addition, recent and detailed data on the resistance of each of the main enteric viruses on fomites are scarce. Many approaches, both physical and chemical, can be used to inactivate enteric viruses, the efficacy of which depends on the virus and the disinfection conditions.

New Proof-of-Concept in Viral Inactivation: Virucidal Efficacy of 405 nm Light Against Feline Calicivirus as a Model for Norovirus Decontamination

The requirement for novel decontamination technologies for use in hospitals is ever present. One such system uses 405 nm visible light to inactivate microorganisms via ROS-generated oxidative damage. Although effective for bacterial and fungal inactivation, little is known about the virucidal effects of 405 nm light. Norovirus (NoV) gastroenteritis outbreaks often occur in the clinical setting, and this study was designed to investigate potential inactivation effects of 405 nm light on the NoV surrogate, feline calicivirus (FCV). FCV was exposed to 405 nm light whilst suspended in minimal and organically-rich media to establish the virucidal efficacy and the effect biologically-relevant material may play in viral susceptibility. Antiviral activity was successfully demonstrated with a 4 Log₁₀ (99.99%) reduction in infectivity when suspended in minimal media evident after a dose of 2.8 kJ cm^-2. FCV exposed in artificial faeces, artificial saliva, blood plasma and other organically rich media exhibited an equivalent level of inactivation using between 50-85% less dose of the light, indicating enhanced inactivation when the virus is present in organically-rich biologically-relevant media. Further research in this area could aid in the development of 405 nm light technology for effective NoV decontamination within the hospital environment.

Diversity changes of microbial communities into hospital surface environments

Previous works have demonstrated considerable variability in hospital cleanliness in Japan, suggesting that contamination is driven by factors that are currently poorly controlled. We undertook 16S rRNA sequence analysis to study population structures of hospital environmental microbiomes to see which factor(s) impacted contamination. One hundred forty-four samples were collected from surfaces of three hospitals with distinct sizes ("A": >500 beds, "B": 100-500 beds, "C": <100 beds). Sample locations of two ward types (Surgical and Internal) included patient room bed table (multiple) (4BT), patient overbed table (multiple) (4OT), patient room sink (multiple) (4S), patient room bed table (single) (SBT), patient overbed table (single) (SOT), patient room sink (single) (SS), nurse desk (ND), and nurse wagon (NW). Total DNA was extracted from each sample, and the 50 samples that yielded sufficient DNA were used for further 16S rRNA sequencing of hospital microbiome populations with cluster analysis. The number of assigned bacterial OTU populations was significantly decreased in hospital "C" compared to the other hospitals. Cluster analysis of sampling locations revealed that the population structure in almost all locations of hospital "C" and some locations in the other hospitals was very similar and unusually skewed with a family, Enterobacteriaceae. Interestingly, locations included patient area (4OT, 4BT, SBT) and nurse area (ND), with a device (NW) bridging the two and a place (4S and SS) shared between patients or visitors. We demonstrated diversity changes of hospital environmental microbiomes with a skewed population, presumably by medical staff pushing NWs or sinks shared by patients or visitors.

Occurrence of hepatitis A and E and norovirus GI and GII in ready-to-eat vegetables in Italy

Fresh vegetables and their ready-to-eat (RTE) salads have become increasingly recognized as potential vehicles for foodborne diseases. The EU Reg. 1441/2007 establishes microbiological criteria for bacterial pathogens for products placed on the market during their shelf-life (i.e. Salmonella spp., Listeria monocytogenes) for pre-cut fruits and vegetables (RTE) whilst it does not address the problem of contamination by enteric viruses. In this study we investigated the contamination by hepatitis A virus (HAV), hepatitis E virus (HEV) and norovirus (NoV) in 911 ready-to-eat vegetable samples taken from products at retail in Apulia and in Lombardia. The vegetable samples were tested using validated real-time PCR (RT-qPCR) assays, ISO standardized virological methods and ISO culturing methods for bacteriological analysis. The total prevalence of HAV and HEV was 1.9% (18/911) and 0.6% (6/911), respectively. None of the samples analysed in this study was positive for NoV, Salmonella spp. or Listeria monocytogenes. The detection of HAV and HEV in RTE salads highlights a risk to consumers and the need to improve production hygiene. Appropriate implementation of hygiene procedures is required at all the steps of the RTE vegetable production chain and this should include monitoring of emerging viral pathogens.

Contamination by Norovirus and Adenovirus on Environmental Surfaces and in Hands of Conscripts in Two Finnish Garrisons

This study investigated the presence of norovirus and adenovirus, especially enteric adenovirus, on the environmental surfaces (n = 481) and military conscripts' hands (n = 109) in two Finnish garrisons (A and B) in 2013 and 2014. A questionnaire study was conducted to reveal possible correlations between viral findings on the conscripts' hands and their acute gastroenteritis symptoms. In addition to the swab samples, 14 fecal samples were obtained for viral analysis. In total, norovirus was present in 9.0 % of the surface swabs in 2013, whereas enteric adenovirus was present in 0.0 % and non-enteric adenovirus in 9.4 %. In the same year, 2.6 % of the hand swabs contained norovirus, 2.6 % enteric adenovirus, and 40.3 % non-enteric adenovirus. Norovirus GI.6 was continually detected on the surfaces of garrison A, and identical virus was detected in some of the fecal samples. In garrison B, two slightly different norovirus GII.4 strains were present on the surfaces. The questionnaires revealed no recent acute gastroenteritis cases in garrison A, but in garrison B, where the norovirus-positive hand swabs were collected, 30.6 % of the conscripts reported of recent symptoms. In 2014, norovirus was rarely detected, but adenovirus was again frequently present, both on the surfaces and hands. Taken together, our results suggest that gastroenteritis outbreaks occurred in 2013, but not in 2014. Due to the low number of hand swabs positive for enteric viruses, no conclusions about associations between viral findings and gastroenteritis symptoms could be drawn. This study increased our understanding of the possible transmission of viruses via contaminated environment and hands.

Swab Sampling Method for the Detection of Human Norovirus on Surfaces

Human noroviruses are a leading cause of epidemic and sporadic gastroenteritis worldwide. Because most infections are either spread directly via the person-to-person route or indirectly through environmental surfaces or food, contaminated fomites and inanimate surfaces are important vehicles for the spread of the virus during norovirus outbreaks. We developed and evaluated a protocol using macrofoam swabs for the detection and typing of human noroviruses from hard surfaces. Compared with fiber-tipped swabs or antistatic wipes, macrofoam swabs allow virus recovery (range 1.2-33.6%) from toilet seat surfaces of up to 700 cm2. The protocol includes steps for the extraction of the virus from the swabs and further concentration of the viral RNA using spin columns. In total, 127 (58.5%) of 217 swab samples that had been collected from surfaces in cruise ships and long-term care facilities where norovirus gastroenteritis had been reported tested positive for GII norovirus by RT-qPCR. Of these 29 (22.8%) could be successfully genotyped. In conclusion, detection of norovirus on environmental surfaces using the protocol we developed may assist in determining the level of environmental contamination during outbreaks as well as detection of virus when clinical samples are not available; it may also facilitate monitoring of effectiveness of remediation strategies.

Evaluation of a Surface Sampling Method for Recovery of Human Noroviruses Prior to Detection Using Reverse Transcription Quantitative PCR

Human noroviruses are the most common cause of acute viral gastroenteritis, and the environmental persistence of these viruses contributes to their transmissibility. Environmental sampling is thus an important tool for investigating norovirus outbreaks and for assessing the effectiveness of cleaning and decontamination regimens. The purpose of this study was to evaluate a sampling material (wipes) for their efficacy at recovering human norovirus from hard surfaces and foods. Dilutions of a human norovirus GII.4 stool specimen derived from an outbreak were applied to hard surfaces (stainless steel and ceramic) and the surfaces of representative foods (green pepper, apple, tomato, and cheese). The viruses were recovered at various times postinoculation using the wipes, followed by RNA extraction and reverse transcription quantitative PCR. Recovery efficiency ranged from 74% to almost 100% for all artificially inoculated hard surfaces and for most fresh produce surfaces. Less efficient recovery was observed for cheese. Viral RNA could be recovered from select surfaces for up to 7 days postinoculation, with a <1 log reduction in genome copy number. In field tests, 24 (11%) of 210 environmental samples collected during winter 2012 from restrooms in North Carolina were presumptively positive for human norovirus, and six of these samples were confirmed as GII.4 by sequencing. These wipes may be a valuable tool for investigations of norovirus outbreaks and studies of norovirus prevalence.

Noroviruses on surfaces: detection, persistence, disinfection and role in environmental transmission

Human noroviruses (HuNoVs), the most common cause of infectious nonbacterial gastroenteritis and the cause of numerous foodborne and hospital outbreaks, are easily transmitted from person-to-person. HuNoVs may persist on surfaces for long periods of time and may be transferred via hands, foods, fomites and air. In this review, studies on methods for detecting HuNoVs on environmental surfaces, such as swabbing, are presented. The review also focuses on recent studies on the efficiency of disinfectants for inactivating HuNoV or its surrogates, such as murine norovirus, on environmental surfaces and hands. Although HuNoV is probably more resistant than MuNoV, this study data adds to the understanding of HuNoV transmission routes and selection of tools for the prevention of HuNoV gastroenteritis outbreaks.

Aerosol transmission of infectious disease

OBJECTIVE

The concept of aerosol transmission is developed to resolve limitations in conventional definitions of airborne and droplet transmission.

METHODS

The method was literature review.

RESULTS

An infectious aerosol is a collection of pathogen-laden particles in air. Aerosol particles may deposit onto or be inhaled by a susceptible person. Aerosol transmission is biologically plausible when infectious aerosols are generated by or from an infectious person, the pathogen remains viable in the environment for some period of time, and the target tissues in which the pathogen initiates infection are accessible to the aerosol. Biological plausibility of aerosol transmission is evaluated for Severe Acute Respiratory Syndrome coronavirus and norovirus and discussed for Mycobacterium tuberculosis, influenza, and Ebola virus.

CONCLUSIONS

Aerosol transmission reflects a modern understanding of aerosol science and allows physically appropriate explanation and intervention selection for infectious diseases.

Test and validation of methods to sample and detect human virus from environmental surfaces using norovirus as a model virus

BACKGROUND

Viruses cause a major proportion of human infections, especially gastroenteritis and respiratory infections in children and adults. Indirect transmission between humans via environmental surfaces may play a role in infections, but methods to investigate this have been sparse.

AIM

To validate and test efficient and reliable procedures to detect multiple human pathogenic viruses on surfaces.

METHODS

The study was divided into two parts. In Part A, six combinations of three different swabs (consisting of cotton, foamed cotton, or polyester head) and two different elution methods (direct lysis or immersion in alkaline glycine buffer before lysis) were tested for efficient recovery of human norovirus GII.7 and mengovirus from artificially contaminated surfaces. In Part B we determined the detection limit for norovirus GI.1 and GII.3 using the best procedure found in Part A linked with a commercial multiplex real-time quantitative polymerase chain reaction detection assay.

FINDINGS

Combining the polyester swab with direct lysis allowed recovery down to 100 and 10 genome copies/cm(2) of norovirus GI.1 and GII.3, respectively. This procedure resulted in the significant highest recovery of both norovirus and mengovirus, whereas no differences in amplification efficiencies were observed between the different procedures.

CONCLUSION

The results indicate that it is possible to detect low concentrations of virus on environmental surfaces. We therefore suggest that a polyester swab, followed by direct lysis, combined with a multiplex qPCR detection assay is an efficient screening tool that merits study of different respiratory and gastrointestinal viruses on environment surfaces.