Norovirus GII.4 detection in environmental samples from patient rooms during nosocomial outbreaks

"The air within: reviewing the sources and health effects of indoor air pollution in households"

Air pollution in the interior of our homes is caused by diverse chemical, physical, and biological entities. This review comprehensively explores the current understanding of sources and health impacts of gaseous and particulate pollutants. Trend analysis of indoor air research worldwide revealed a quantum jump of 2.8 times in the number of publications during the last ten years. Indoor air pollutants are innumerable, but only a few are widely prevalent in most households. The qualitative complexity of pollutants translates to different health problems, including respiratory diseases, cardiovascular conditions, cancer, and deaths. There exist wide-scale disparities in the negative impacts among different economic strata, genders, and age groups; children and elderly populations are more vulnerable. In developing countries, pollutants primarily arise from traditional sources, whereas in developed countries, pollutants from non-conventional sources are comparatively significant. Only a few countries have indoor air regulations, policies, monitoring plans and effective enforcement.

Aerosol Transmission of Norovirus

Norovirus (NoV) is a major cause of acute gastroenteritis outbreaks worldwide. A comprehensive understanding of the transmission mode is of great significance for the prevention and control of the NoV infection. Currently, the transmission modes of NoV include contact, food-borne, water-borne and aerosol transmission. The first three modes are more common, while aerosol transmission is seldom reported. In this paper, the source, generation mechanism, infectivity, sampling and related outbreaks of NoV aerosol are summarized and discussed.

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.

Unveiling of Pyrimidindinones as Potential Anti-Norovirus Agents-A Pharmacoinformatic-Based Approach

The RNA-dependent RNA polymerase (RdRp) receptor is an attractive target for treating human norovirus (HNV). A computer-aided approach like e-pharmacophore, molecular docking, and single point energy calculations were performed on the compounds retrieved from the Development Therapeutics Program (DTP) AIDS Antiviral Screen Database to identify the antiviral agent that could target the HNV RdRp receptor. Induced-fit docking (IFD) results showed that compounds ZINC1617939, ZINC1642549, ZINC6425208, ZINC5887658 and ZINC32068149 bind with the residues in the active site-B of HNV RdRp receptor via hydrogen bonds, salt bridge, and electrostatic interactions. During the molecular dynamic simulations, compounds ZINC6425208, ZINC5887658 and ZINC32068149 displayed an unbalanced backbone conformation with HNV RdRp protein, while ZINC1617939 and ZINC1642549 maintained stability with the protein backbone when interacting with the residues. Hence, the two new concluding compounds discovered by the computational approach can be used as a chemotype to design promising antiviral agents aimed at HNV RdRp.

Risk of environmental transmission of norovirus infection from prior room occupants

BACKGROUND

Environmental contamination of norovirus (NoV) is believed to be a significant source for further transmission in hospitals.

AIM

To investigate the risk of acquiring NoV in a cleaned room previously occupied by a patient with NoV infection. The risk of having a roommate with recent NoV infection was also assessed.

METHODS

In a retrospective cohort, comprising 33,788 room stays at five infectious Disease wards in southern Sweden from 2013 to 2018, the risk of acquiring NoV infection after admission to an exposed or non-exposed room was analysed with uni- and multivariable statistical analysis, controlling for age, colonization pressure and any roommate. RNA sequencing of the NoV strains involved in suspected room transmission was also performed.

RESULTS

Five of the 1106 patients exposed to a room with a prior occupant with NoV infection and 49 in the non-exposed group acquired NoV infection. An association between NoV acquisition was found in the univariable analysis (odds ratio (OR) 3.3, P=0.01), but not when adjusting for potential confounders (OR 1.9, P=0.2). Sequencing of the NoV samples showed that only two of the five exposed patients with acquired NoV infection were infected by identical strains to the prior room occupant, inferring a room transmission risk of 0.2% (95% confidence interval 0.05-0.78%). None of the 52 patients who shared room with a roommate with NoV symptoms resolved for ≥48 h acquired NoV infection.

CONCLUSIONS

In absolute terms, the risk of room transmission of NoV is low. Discontinuation of isolation ≥48 h after resolution of symptoms seems adequate.

Risk factors for norovirus infection in healthcare workers during nosocomial outbreaks: a cross-sectional study

Background

Norovirus outbreaks cause severe medico-socio-economic problems affecting healthcare workers and patients. The aim of the study was to investigate prevalence of norovirus infection and risk factors for infection in healthcare workers during nosocomial outbreaks.

Methods

A cross-sectional study of norovirus infections in healthcare workers was performed in seven outbreak wards in a large university hospital. Packs (swab for rectal sampling, and questionnaire) were posted to healthcare workers on notification of a ward outbreak. Rectal samples were examined with norovirus-specific real-time PCR. Replies from questionnaires were analysed using logistic regression models with norovirus genogroup (G)II positive findings as dependent variable. The results are expressed as odds ratios (OR) with 95% confidence intervals (CI). Sequencing and phylogenetic analyses (1040 nucleotides) were used to characterize norovirus strains from healthcare workers. Cluster analyses included norovirus GII.4 strains detected in ward patients during the ongoing outbreaks.

Results

Of 308 packs issued to healthcare workers, 129 (42%) were returned. norovirus GII was detected in 26 healthcare workers (20.2%). Work in cohort care (OR 4.8, 95% CI 1.4–16.3), work in wards for patients with dementia (OR 13.2, 95% CI 1.01–170.7), and having diarrhoea, loose stools or other gastrointestinal symptoms the last week (OR 7.7, 95% CI 2.5–27.2) were associated with increased norovirus prevalence in healthcare workers. Sequencing revealed norovirus GII.4 in healthcare workers samples, and strains detected in healthcare workers and ward patients during a given ward outbreak showed ≥ 99% similarity.

Conclusion

Norovirus positive findings in healthcare workers were strongly associated with symptomatic infection, close contact with sick patients, and dementia nursing.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13756-021-00979-8.

Development of a recombinase-aided amplification assay for rapid detection of human norovirus GII.4

Background

Human noroviruses are one of the main causes of foodborne illnesses and represent a serious public health concern. Rapid and sensitive assays for human norovirus detection are undoubtedly necessary for clinical diagnosis, especially in regions without more sophisticated equipment.

Method

The rapid reverse transcription recombinase-aided amplification (RT-RAA) is a fast, robust and isothermal nucleic acid detection method based on enzyme reaction. This method can complete the sample detection at 39 °C in 30 min. In this study, we successfully established a rapid reverse transcription recombinase-aided amplification (RT-RAA) assay for the detection of human norovirus GII.4 and applied this assay to clinical samples, as well as comparison with commercial reverse transcription real-time fluorescence quantitative PCR (RT-qPCR).

Results

At 95% probability, the detection sensitivity of RT-RAA was 3.425 log10 genomic copies (LGC)/reaction. Moreover, no cross-reaction was observed with other norovirus genogroups and other common foodborne viruses. Stool samples were examined by RT-RAA and reverse transcription quantitative real-time polymerase chain reaction (RT-qPCR). Compared of RT-qPCR, kappa values for human norovirus detection with RT-RAA were 0.894 (p < 0.001), indicating that both assays were in agreement.

Conclusion

This RT-RAA assay provides a rapid, specific, and sensitive assay for human norovirus detection and is suitable for clinical testing.

Risk Factors and Clinical Profile of Sapovirus-associated Acute Gastroenteritis in Early Childhood: A Nicaraguan Birth Cohort Study

BACKGROUND

Sapovirus is increasingly recognized as an important cause of acute gastroenteritis (AGE) in children. We identified risk factors and characterized the clinical profile of sapovirus AGE in a birth cohort in León, Nicaragua.

METHODS

We conducted a case-control study nested within a birth cohort (n = 444). Fieldworkers conducted weekly household AGE surveillance. AGE stools were tested for sapovirus by reverse transcriptase quantitative polymerase chain reaction. For each first sapovirus episode, we selected 2 healthy age-matched controls and estimated independent risk factors of sapovirus AGE using conditional logistic regression. We compared clinical characteristics of sapovirus AGE episodes with episodes associated with other etiologies and identified co-infections with other enteric pathogens.

RESULTS

From June 2017 to July 2019, we identified 63 first sapovirus AGE episodes and selected 126 controls. Having contact with an individual with AGE symptoms and vaginal delivery were independent risk factors for sapovirus AGE. All cases experienced diarrhea, lasting a median 6 days; 23% experienced vomiting. Compared with children with AGE due to another etiology, sapovirus AGE was similar in severity, with less reported fever. Most cases experienced co-infections and were more likely than controls to be infected with diarrheagenic Escherichia coli or astrovirus.

CONCLUSIONS

Sapovirus was a commonly identified AGE etiology in this Central American setting, and symptoms were similar to AGE associated with other etiologies. The association between vaginal delivery and sapovirus is a novel finding. Gut microbiome composition might mediate this relationship, or vaginal delivery might be a proxy for other risk factors. Further investigation into more specific biological mechanisms is warranted.

Sources of Airborne Norovirus in Hospital Outbreaks

BACKGROUND

Noroviruses are the major cause of viral gastroenteritis. Disease transmission is difficult to prevent and outbreaks in health-care facilities commonly occur. Contact with infected persons and contaminated environments are believed to be the main routes of transmission. However, noroviruses have recently been found in aerosols and airborne transmission has been suggested. The aim of our study was to investigate associations between symptoms of gastroenteritis and the presence of airborne norovirus, and to investigate the size of norovirus-carrying particles.

METHODS

Air sampling was repeatedly performed close to 26 patients with norovirus infections. Samples were analyzed for norovirus RNA by reverse transcription quantitative polymerase chain reaction. The times since each patient's last episodes of vomiting and diarrhea were recorded. Size-separating aerosol particle collection was performed.

RESULTS

Norovirus RNA was found in 21 (24%) of 86 air samples from 10 different patients. Only air samples during outbreaks, or before a succeeding outbreak, tested positive for norovirus RNA. Airborne norovirus RNA was also strongly associated with a shorter time period since the last vomiting episode (odds ratio 8.1; P = .04 within 3 hours since the last vomiting episode). The concentrations of airborne norovirus ranged from 5-215 copies/m3, and detectable amounts of norovirus RNA were found in particles <0.95 µm and >4.51 µm.

CONCLUSIONS

The results suggest that recent vomiting is the major source of airborne norovirus and imply a connection between airborne norovirus and outbreaks. The presence of norovirus RNA in submicrometre particles indicates that airborne transmission can be an important transmission route.

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.

Identification of a norovirus outbreak on a hematopoietic stem cell transplant unit and development and implementation of a novel infection prevention algorithm for controlling transmission

Controlling norovirus transmission in units with immunocompromised patients is challenging. We present a cluster of norovirus cases that occurred on a stem-cell transplant unit and the prevention efforts that were implemented to limit the outbreak. Protocols developed to control this cluster may provide a model for other facilities.

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

BACKGROUND

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

Comparison of Swab Sampling Methods for Norovirus Recovery on Surfaces

Human noroviruses (HuNoVs) can be easily transferred by the contacts of humans or fomites. Swab sampling methods are widely used for recovering HuNoVs from small surfaces of various fomites or hard-to-reach locations and swab sampling conditions are important for the accurate detection of HuNoVs, which have a low infectious dose and relatively long persistence under a range of environmental conditions. Therefore, to determine the suitable swab sampling method for recovering HuNoVs from various surfaces, we evaluated combinations of four swab materials (cotton, microdenier polyester [a type of microfiber], polyurethane foam, and rayon) and three elution buffer solutions (phosphate-buffered saline [PBS], PBS with 0.2% Tween-80, and 3% beef extract-50 mM glycine [pH 9.5]). First, we inoculated HuNoVs or murine noroviruses (MuNoVs), the surrogate of HuNoVs, onto test coupons (10 × 10 cm) consisting of three common surface materials (high-density polyethylene, stainless steel, and wood). Coupons were swabbed using a combination of each swab material and elution buffer, and the viral recovery was measured by real-time reverse transcription quantitative polymerase chain reaction (RT-qPCR) or plaque assay. By RT-qPCR, we confirmed that the cotton swab-PBS and microdenier polyester-PBS combinations had recovery efficiencies greater than 80% for viruses on plastic and stainless steel surfaces. The cotton swab-PBS combination had the highest recovery efficiency on all surface materials via the plaque assay. Therefore, a cotton or a microdenier polyester swab with PBS could be a useful method for sampling HuNoVs on various surfaces.

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.

Detection of Pathogenic Viruses in the Ambient Air in Seoul, Korea

The possible transport of pathogenic microorganisms during Asian dust events could be an important concern for health workers; however, this is still uncertain owing to a lack of supporting evidence. The present study aimed to investigate the presence of pathogenic microorganisms in air samples collected during the Asian and non-Asian dust periods. Between March and September 2016, air samples were collected at three weather observation stations in Seoul using a high-volume air sampler. Multiplex PCR was performed using the Allplex™ respiratory and gastrointestinal panel assay kits to detect 46 microorganisms. RT-PCR was performed for klassevirus, Aichivirus, and human parechovirus (HPeV) detection. In total, 71 air samples were collected during the Asian (8 samples) and non-Asian (63 samples) dust events. During an Asian dust event, only one human rhinovirus (HRV)-positive air sample was collected on April 23. During the non-Asian dust period, HRV, HPeV, norovirus (NoV), enteroaggregative Escherichia coli (EAEC), enterotoxigenic E. coli (ETEC), and Blastocystis hominis were detected in four, two, one, one, one, and one air samples, respectively. Pathogenic viruses were mostly detected in ambient air samples during the non-Asian dust period, which suggests a possible air-borne transmission of viral pathogens; however, the role of Asian dust in epidemics caused by pathogenic viruses is unclear.

Healthcare-associated infections: potential for prevention through vaccination

The challenge of healthcare-associated infections is compounded by the higher incidence of resistant organisms and the decreasing utility of antimicrobial agents. Historic and current vaccines have already contributed to reductions in healthcare-associated infections, and future vaccines have the potential to reduce these infections further. Through examples of bacterial and viral vaccines, this review will attempt to chart the way forward.

Airborne or Fomite Transmission for Norovirus? A Case Study Revisited

Norovirus infection, a highly prevalent condition associated with a high rate of morbidity, comprises a significant health issue. Although norovirus transmission mainly occurs via the fecal-oral and vomit-oral routes, airborne transmission has been proposed in recent decades. This paper re-examines a previously described norovirus outbreak in a hotel restaurant wherein airborne transmission was originally inferred. Specifically, the original evidence that suggested airborne transmission was re-analyzed by exploring an alternative hypothesis: could this outbreak instead have occurred via fomite transmission? This re-analysis was based on whether fomite transmission could have yielded similar attack rate distribution patterns. Seven representative serving pathways used by waiters were considered, and the infection risk distributions of the alternative fomite transmission routes were predicted using a multi-agent model. These distributions were compared to the reported attack rate distribution in the original study using a least square methods approach. The results show that with some reasonable assumptions of human behavior patterns and parameter values, the attack rate distribution corresponded well with that of the infection risk via the fomite route. This finding offers an alternative interpretation of the transmission routes that underlay this particular norovirus outbreak and an important consideration in the development of infection control guidelines and the investigation of similar norovirus outbreaks in future.

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.

Slow Clearance of Norovirus following Infection with Emerging Variants of Genotype GII.4 Strains

The emergence of new norovirus genotype GII.4 strains is associated with widespread norovirus epidemics. Extended periods of viral shedding can contribute to the epidemic potential of norovirus. To describe the duration of viral shedding in infections with novel emerging GII.4 strains versus infections with previously circulating strains, we performed a prospective cohort study of patients hospitalized with norovirus gastroenteritis during separate winter seasons. Rectal swab samples were obtained at the time of inclusion and weekly during follow-ups. The subgenotype strain was determined from capsid sequences. The outcome was defined by the detection of virus for >14 days (slow clearance) or by the detection of negative samples within 14 days (rapid clearance). Two major epidemic GII.4 strains emerged during the study period, GII.4 New Orleans 2009, in 2010, and GII.4 Sydney 2012, in 2012. From these two seasons, sequences were available from 24 cases where the duration of shedding could be determined. The median age of the patients was 83 years and 50% were women. The majority of patients were infected with virus that clustered with the respective season's epidemic strain (n = 19), whereas 5 patients had previously circulating strains (3 were Den Haag 2006b, in 2010, and 2 were New Orleans 2009, in 2012). Among the patients infected with an epidemic strain, the proportion who shed virus for >14 days was significantly higher (16/19 [84%] versus 1/5 [20%], P = 0.01). In summary, a slow clearance of norovirus from stool was more common in infections with novel epidemic GII.4 strains. This suggests that the average duration of shedding may be longer during seasons when new GII.4 strains have emerged.

Feasibility of viral dust infection via air movement and dispersion of dried viral particles from the floor

The contributions of splash from vomiting and the dispersion of dried-up virus from a contaminated floor surface to community gastroenteritis outbreaks caused by Norovirus (NoV) were evaluated, using Feline calicivirus (FCV) as an NoV surrogate. There was no difference in the size distribution of FCV-containing particles around 0.75 µm) collected from a virus-sprayed chamber 1 and 12 hr after nebulization. FCV clearly dispersed after hitting a floor surface contaminated with dried virus. These results suggest that NoV can likely form airborne droplet nuclei, and dust may be the main route of infection transmission. J. Med. Virol. 89:931-935, 2017. © 2016 Wiley Periodicals, Inc.

Development of a Nanobody-Based Lateral Flow Immunoassay for Detection of Human Norovirus

We previously identified a Nanobody (termed Nano-85) that bound to a highly conserved region on the norovirus capsid. In this study, the Nanobody was biotinylated and gold conjugated for a lateral flow immunoassay (termed Nano-IC). We showed that the Nano-IC assay was capable of detecting at least four antigenically distinct GII genotypes, including the newly emerging GII.17. In the clinical setting, the Nano-IC assay had sensitivities equivalent to other commercially available lateral flow systems. The Nano-IC method was capable of producing results in ~5 min, which makes this method useful in settings that require rapid diagnosis, such as cruise ship outbreaks and elder care facilities. The Nano-IC assay has several advantages over antibody-based IC methods: for example, Nanobodies can be readily produced in large quantities, they are generally more stable than conventional antibodies, and the Nanobody binding sites can be easily obtained by X-ray crystallography.

Human noroviruses are the dominant cause of outbreaks of acute gastroenteritis. These viruses are usually detected by molecular methods, including reverse transcriptase PCR (RT-PCR) and enzyme-linked immunosorbent assay (ELISA). Human noroviruses are genetically and antigenically diverse, with two main genogroups that are further subdivided into over 40 different genotypes. During the past decade, genogroup 2 genotype 4 (GII.4) has dominated in most countries, but recently, viruses belonging to GII.17 have increased in prevalence in a number of countries. A number of commercially available ELISAs and lateral flow immunoassays were found to have lower sensitivities to the GII.17 viruses, indicating that the antibodies used in these methods may not have a high level of cross-reactivity. In this study, we developed a rapid Nanobody-based lateral flow immunoassay (Nano-immunochromatography [Nano-IC]) for the detection of human norovirus in clinical specimens. The Nano-IC assay detected virions from two GII.4 norovirus clusters, which included the current dominant strain and a novel variant strain. The Nano-IC method had a sensitivity of 80% and specificity of 86% for outbreak specimens. Norovirus virus-like particles (VLPs) representing four genotypes (GII.4, GII.10, GII.12, and GII.17) could be detected by this method, demonstrating the potential in clinical screening. However, further modifications to the Nano-IC method are needed in order to improve this sensitivity, which may be achieved by the addition of other broadly reactive Nanobodies to the system.

IMPORTANCE We previously identified a Nanobody (termed Nano-85) that bound to a highly conserved region on the norovirus capsid. In this study, the Nanobody was biotinylated and gold conjugated for a lateral flow immunoassay (termed Nano-IC). We showed that the Nano-IC assay was capable of detecting at least four antigenically distinct GII genotypes, including the newly emerging GII.17. In the clinical setting, the Nano-IC assay had sensitivities equivalent to other commercially available lateral flow systems. The Nano-IC method was capable of producing results in ~5 min, which makes this method useful in settings that require rapid diagnosis, such as cruise ship outbreaks and elder care facilities. The Nano-IC assay has several advantages over antibody-based IC methods: for example, Nanobodies can be readily produced in large quantities, they are generally more stable than conventional antibodies, and the Nanobody binding sites can be easily obtained by X-ray crystallography.

Decontamination of indoor air to reduce the risk of airborne infections: Studies on survival and inactivation of airborne pathogens using an aerobiology chamber

BACKGROUND

Although indoor air can spread many pathogens, information on the airborne survival and inactivation of such pathogens remains sparse.

METHODS

Staphylococcus aureus and Klebsiella pneumoniae were nebulized separately into an aerobiology chamber (24.0 m³). The chamber's relative humidity and air temperature were at 50% ± 5% and 20°C ± 2°C, respectively. The air was sampled with a slit-to-agar sampler. Between tests, filtered air purged the chamber of any residual airborne microbes.

RESULTS

The challenge in the air varied between 4.2 log₁₀ colony forming units (CFU)/m³ and 5.0 log₁₀ CFU/m³, sufficient to show a ≥3 log₁₀ (≥99.9%) reduction in microbial viability in air over a given contact time by the technologies tested. The rates of biologic decay of S aureus and K pneumoniae were 0.0064 ± 0.00015 and 0.0244 ± 0.009 log₁₀ CFU/m³/min, respectively. Three commercial devices, with ultraviolet light and HEPA (high-efficiency particulate air) filtration, met the product efficacy criterion in 45-210 minutes; these rates were statistically significant compared with the corresponding rates of biologic decay of the bacteria. One device was also tested with repeated challenges with aerosolized S aureus to simulate ongoing fluctuations in indoor air quality; it could reduce each such recontamination to an undetectable level in approximately 40 minutes.

CONCLUSIONS

The setup described is suitable for work with all major classes of pathogens and also complies with the U.S. Environmental Protection Agency's guidelines (2012) for testing air decontamination technologies.

Generic aspects of the airborne spread of human pathogens indoors and emerging air decontamination technologies

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Indoor air is an important vehicle for a variety of human pathogens.

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Review of airborne transmission of infectious agents from experimental and field studies, predisposing to establish air-surface-air nexus and possible ways of transmission to susceptible hosts.

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An overview of the methods for experimentally generating and recovering airborne human pathogens and environmental factors affecting their survival in air.

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Current and emerging technologies for decontamination of indoor air for human pathogens.

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Design, establishment, and validation of a room-size aerobiology chamber meeting the U.S. Environmental Protection Agency guidelines (2012) that can be used for assessment of air-decontamination technologies.

Indoor air can be an important vehicle for a variety of human pathogens. This review provides examples of airborne transmission of infectious agents from experimental and field studies and discusses how airborne pathogens can contaminate other parts of the environment to give rise to secondary vehicles leading air-surface-air nexus with possible transmission to susceptible hosts. The following groups of human pathogens are covered because of their known or potential airborne spread: vegetative bacteria (staphylococci and legionellae), fungi (Aspergillus, Penicillium, and Cladosporium spp and Stachybotrys chartarum), enteric viruses (noro- and rotaviruses), respiratory viruses (influenza and coronaviruses), mycobacteria (tuberculous and nontuberculous), and bacterial spore formers (Clostridium difficile and Bacillus anthracis). An overview of methods for experimentally generating and recovering airborne human pathogens is included, along with a discussion of factors that influence microbial survival in indoor air. Available guidelines from the U.S. Environmental Protection Agency and other global regulatory bodies for the study of airborne pathogens are critically reviewed with particular reference to microbial surrogates that are recommended. Recent developments in experimental facilities to contaminate indoor air with microbial aerosols are presented, along with emerging technologies to decontaminate indoor air under field-relevant conditions. Furthermore, the role that air decontamination may play in reducing the contamination of environmental surfaces and its combined impact on interrupting the risk of pathogen spread in both domestic and institutional settings is discussed.

Contamination of healthcare workers' mobile phones by epidemic viruses

Mobile phones (MPs) are potential reservoirs of nosocomial bacteria, but few data are available concerning viruses. We aimed to evaluate the presence of virus RNA from epidemic viruses including metapneumovirus, respiratory syncytial virus, influenza viruses, rotavirus (RV) and norovirus on the MPs used by healthcare workers (HCWs) and to relate it to hygiene measures. An anonymous behavioural questionnaire about MP use at hospital was administered to the HCWs of four adult and paediatric departments of a university hospital. After sampling personal (PMP) and/or professional MPs (digital enhanced cordless telephone, DECT), virus RNAs were extracted and amplified by one-step real-time reverse transcription-quantitative PCR. The molecular results were analysed in a masked manner in relation to the behavioural survey. Questionnaires from 114 HCWs (25 [corrected] senior physicians, 30 residents, 32 nurses, 27 nurses' assistants) working either in adult (n = 58) or paediatric (n = 56) departments were analysed. Medical personnel used their PMP more frequently than paramedical HCWs (33/65 vs. 10/59, p <0.001). MPs were used during care more frequently in adult wards than in paediatric ones (46/58 vs. 27/56, p <0.001). Virus RNA was detected on 42/109 (38.5%) collected MPs, with RV found on 39, respiratory syncytial virus on three and metapneumovirus on one. The presence of virus RNA was significantly associated with MPs from the paediatric HCWs (p <0.001). MPs routinely used in hospital, even during care, can host virus RNA, especially RV. Promotion of frequent hand hygiene before and after MP use, along with frequent cleaning of MPs, should be encouraged.

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.

Hydrogen Peroxide Vapor Decontamination in a Patient Room Using Feline Calicivirus and Murine Norovirus as Surrogate Markers for Human Norovirus

OBJECTIVE

To determine whether hydrogen peroxide vapor (HPV) could be used to decontaminate caliciviruses from surfaces in a patient room.

DESIGN

Feline calicivirus (FCV) and murine norovirus (MNV) were used as surrogate viability markers to mimic the noncultivable human norovirus. Cell culture supernatants of FCV and MNV were dried in triplicate 35-mm wells of 6-well plastic plates. These plates were placed in various positions in a nonoccupied patient room that was subsequently exposed to HPV. Control plates were positioned in a similar room but were never exposed to HPV.

METHODS

Virucidal activity was measured in cell culture by reduction in 50% tissue culture infective dose titer for FCV and by both 50% tissue culture infective dose titer and plaque reduction for MNV.

RESULTS

Neither viable FCV nor viable MNV could be detected in the test room after HPV treatment. At least 3.65 log reduction for FCV and at least 3.67 log reduction for MNV were found by 50% tissue culture infective dose. With plaque assay, measurable reduction for MNV was at least 2.85 log units.

CONCLUSIONS

The successful inactivation of both surrogate viruses indicates that HPV could be a useful tool for surface decontamination of a patient room contaminated by norovirus. Hence nosocomial spread to subsequent patients can be avoided.

Analysis of uncommon norovirus recombinants from Manaus, Amazon region, Brazil: GII.P22/GII.5, GII.P7/GII.6 and GII.Pg/GII.1

Norovirus (NoV) is responsible for outbreaks and sporadic cases of nonbacterial acute gastroenteritis in humans worldwide. The virus consists of small round particles containing a single-stranded RNA genome that is divided into three Open Reading Frames. NoV evolves via mechanisms of antigenic drift and recombination, which lead to the emergence of new strains that are capable of causing global epidemics. Recombination usually occurs in the ORF1/ORF2 overlapping region and generates strains with different genotypes in the polymerase and capsid region. The primary objective of this study was to analyze recombination in positive-NoV samples. Specimens were collected during 2011, 2012 and 2014, from children under two years of age presenting gastrointestinal symptoms such as vomiting and diarrhea. The partial polymerase (B region), capsid (D region) genes and the ORF1-ORF2 overlap regions were sequenced in each sample. The recombinant analyses were performed in the Simplot software v.3.5.1 and RDP4 Beta v. 4.6 program. These analyses showed that GII.Pg/GII.1, GII.P7/GII.6, and GII.P22/GII.5 were recombinant strains. To our knowledge, this is the first time that the GII.P22/GII.5 and GII.Pg/GII.1 strains were described in South America and the GII.P7/GII.6 was detected in Northern of Brazil.

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

BACKGROUND

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

Structural Evolution of the Emerging 2014-2015 GII.17 Noroviruses

Recent reports suggest that human genogroup II genotype 17 (GII.17) noroviruses are increasing in prevalence. We analyzed the evolutionary changes of three GII.17 capsid protruding (P) domains. We found that the GII.17 P domains had little cross-reactivity with antisera raised against the dominant GII.4 strains. X-ray structural analysis of GII.17 P domains from 2002 to 2014 and 2015 suggested that surface-exposed substitutions on the uppermost part of the P domain might have generated a novel 2014-2015 GII.17 variant.

Norovirus in healthcare settings

Purpose of review

To provide an overview of the burden of norovirus disease in healthcare settings and the factors responsible for outbreaks in these institutions; to assess progress on interventions aimed at reducing the burden of norovirus disease.

Recent findings

Norovirus outbreaks in healthcare settings are driven by confluence of viral diversity, the built environment, and host factors. Some of these characteristics may be modifiable and the target of successful interventions.

Summary

Most norovirus outbreaks in hospital and residential care institutions are associated with a particular genotype, known as GII.4. The persistence of norovirus is associated with strain diversity, which is driven by immune evasion and viral adaptation to interaction with a variety of human histo-blood group antigens. The healthcare environment presents serious challenges for control, both because of the physical structure of the built space and the high levels of contact among patient populations who may have compromised hygiene. Increased vulnerability among the populations in healthcare institutions is likely to be multifactorial and may include the following: nutritional status, immunodeficiency or senescence, chronic inflammation, and microbiome alterations. Current control measures are based on general infection control principles, and treatment is mainly supportive and nonspecific. Vaccines and antiviral agents are being developed with promising results, but none are currently available.

Detection and quantification of airborne norovirus during outbreaks in healthcare facilities

BACKGROUND

Noroviruses are responsible for at least 50% of all gastroenteritis outbreaks worldwide. Noroviruses GII can infect humans via multiple routes including direct contact with an infected person, fecal matter, or vomitus, and contact with contaminated surfaces. Although norovirus is an intestinal pathogen, aerosols could, if inhaled, settle in the pharynx and later be swallowed. The aims of this study were to investigate the presence of norovirus GII bioaerosols during gastroenteritis outbreaks in healthcare facilities and to study the in vitro effects of aerosolization and air sampling on the noroviruses using murine norovirus as a surrogate.

METHODS

A total of 48 air samples were collected during norovirus outbreaks in 8 healthcare facilities. Samples were taken 1 m away from each patient, in front of the patient's room and at the nurses' station. The resistance to aerosolization stress of murine norovirus type 1 (MNV-1) bioaerosols was also tested in vitro using an aerosol chamber.

RESULTS

Norovirus genomes were detected in 6 of 8 healthcare centers. The concentrations ranged from 1.35 × 10(1) to 2.35 × 10(3) genomes/m(3) in 47% of air samples. MNV-1 preserved its infectivity and integrity during in vitro aerosol studies.

CONCLUSIONS

Norovirus genomes are frequently detected in the air of healthcare facilities during outbreaks, even outside patients' rooms. In addition, in vitro models suggest that this virus may withstand aerosolization.

Burden of norovirus in healthcare facilities and strategies for outbreak control

Norovirus is the most frequently occurring cause of community-acquired acute gastroenteritis in people of all ages. It is also one of the most frequent causes of outbreaks in healthcare settings, affecting both long-term care facilities and acute care hospitals. Whereas norovirus gastroenteritis is typically mild and resolves without medical attention, healthcare-associated infections often affect vulnerable populations, resulting in severe infections and disruption of healthcare services. Globally, most norovirus outbreaks in hospitals and residential care institutions are associated with genogroup II type 4 (GII.4) strains. Recent data demonstrate that excess mortality occurs during outbreak periods in healthcare facilities. Nosocomial outbreaks can result in large economic and societal costs. Current control measures for norovirus are largely based on general infection control principles, and treatment is mainly supportive and non-specific. While neither vaccines nor antiviral agents are currently available, both are being developed with encouraging results.

Norovirus Genotypes in Hospital Settings: Differences Between Nosocomial and Community-Acquired Infections

BACKGROUND

Norovirus (NoV) is a major cause of gastroenteritis and hospital outbreaks, leading to substantial morbidity and direct healthcare expenses as well as indirect societal costs. The aim of the study was to estimate the proportion of nosocomial NoV infections among inpatients testing positive for NoV in Denmark, 2002-2010, and to study the distribution of NoV genotypes among inpatients with nosocomial and community-acquired NoV infections, respectively.

METHODS

Admission and stool sampling dates from 3656 NoV-infected patients were used to estimate the proportion of nosocomial infections. The associations between nosocomial infection and patient age, sex, and NoV genotype GII.4 were examined.

RESULTS

Of the 3656 inpatients, 63% were classified as having nosocomial infections. Among these, 9 capsid and 8 polymerase NoV genotypes were detected, whereas in the smaller group of inpatients with community-acquired infections, 12 capsid and 9 polymerase genotypes were detected. Nosocomial NoV infections were associated with age ≥60 years and infections with genotype GII.4.

CONCLUSIONS

The majority of NoV infections in hospitalized patients were nosocomial. Nosocomial infection was mainly associated with older age but also with the specific genotype GII.4. The genotypes in community-acquired NoV infections were more heterogeneous than in nosocomial infections.