Case-control studies can be successful in identiffying risk factors for nosocomial outbreaks of diarrhea. High levels of rotavirus antibodies in mothers may not protect infants. The environment may be the most important reservoir of rotavirus during outbreaks.

In this study, Norwalk-like virus (NLV) RNA was detected by reverse transcriptase PCR (RT-PCR) in sewage water concentrates. Sequence analysis of the RT-PCR products revealed identical sequences in stools of patients and related sewage samples. In 6 of 11 outbreak-unrelated follow-up samples, multiple NLV genotypes were present. Levels as high as 107 RNA-containing particles per liter were found. These data show that high loads of NLVs may be present in sewage and warrant further studies addressing the efficacy of NLV removal by sewage water treatment processes.