Norovirus in the hospital setting: virus introduction and spread within the hospital environment

Morter, S.; Bennet, Grant; Fish, Jason E.; Richards, Judith; Allen, David J.; Nawaz, Sameena; Iturriza‐Gómara, Miren; Brolly, S.; Gray, James J.

doi:10.1016/j.jhin.2010.09.035

Cited by 80 publications

(84 citation statements)

References 21 publications

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“…Genomic diversity and the prevalence of NoV GII.4 add to the complexity of nosocomial infections (34), as seen in this study, in which 11 NoV GII.4 variants (differing by 0.7 to 3.7%, 1,040 nt) were detected in eight wards in four separate buildings during the 5-month study (Fig. 1).…”

Section: Discussionsupporting

confidence: 54%

Norovirus GII.4 Detection in Environmental Samples from Patient Rooms during Nosocomial Outbreaks

et al. 2014

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c Norovirus (NoV) is an important cause of nosocomial gastroenteric outbreaks. This 5-month study was designed to characterize NoV contamination and airborne dispersal in patient rooms during hospital outbreaks. Air vents, overbed tables, washbasins, dust, and virus traps designed to collect charged particles from the air were swabbed to investigate the possibility of NoV contamination in patient rooms during outbreaks in seven wards and in an outbreak-free ward. Symptomatic inpatients were also sampled. Nucleic acid extracts of the samples were examined for NoV RNA using genogroup I (GI) and GII real-time reverse transcription-PCR (RT-PCR). The NoV strains were characterized by RT-PCR, sequencing, and phylogenetic analysis of the RNA-dependent RNA-polymerase-N/S capsid-coding region (1,040 nucleotides [nt]). Patient strains from two outbreaks in one ward were sequenced across the RNA-dependent-RNA-polymerase major capsid-coding region (2.5 kb), including the hypervariable P2 domain. In the outbreak wards, NoV GII was detected in 48 of 101 (47%) environmental swabs and 63 of 108 patients (58%); NoV genotype II.4 was sequenced from 18 environmental samples, dust (n ‫؍‬ 8), virus traps (n ‫؍‬ 4), surfaces (n ‫؍‬ 6), and 56 patients. In contrast, NoV GII was detected in 2 (GII.4) of 28 (7%) environmental samples and in 2 (GII.6 and GII.4) of 17 patients in the outbreak-free ward. Sequence analyses revealed a high degree of similarity (>99.5%, 1,040 nt) between NoV GII.4 environmental and patient strains from a given ward at a given time. The strains clustered on 11 subbranches of the phylogenetic tree, with strong correlations to time and place. The high nucleotide similarity between the NoV GII.4 strains from patients and their hospital room environment provided molecular evidence of GII.4 dispersal in the air and dust; therefore, interventional cleaning studies are justified.

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Section: Discussionsupporting

confidence: 54%

Norovirus GII.4 Detection in Environmental Samples from Patient Rooms during Nosocomial Outbreaks

et al. 2014

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“…Consequently, the underascertainment of NoV patients might be even higher than we report here. Furthermore, we did not address undiagnosed NoV infections among hospital personnel, although recent studies have indicated that infected personnel can play an important role in the NoV transmission chain (16). Hence, appropriate collection and testing in both patients and personnel will be required for developing new evidence-based strategies to prevent the introduction and spread of NoV (20).…”

Section: Discussionmentioning

confidence: 99%

Unrecognized Norovirus Infections in Health Care Institutions and Their Clinical Impact

Beersma

Sukhrie²,

Bogerman³

et al. 2012

J Clin Microbiol

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e Noroviruses (NoVs) have emerged as the leading cause of acute viral gastroenteritis (GE) in humans. Although diagnostic facilities have greatly improved, significant underdiagnosis of NoV in hospitals may still occur, thereby increasing clinical burden and nosocomial spread. We evaluated the underdiagnosis of sporadic NoV infections in a tertiary care hospital and estimated its clinical impact. From December 2008 until July 2009, fecal samples specifically referred for bacterial but not viral examination were retrospectively tested for NoV by real-time PCR. The clinical and virological data from patients with undiagnosed NoV infection (missed patients) were evaluated and compared with those from patients with recognized NoV. During the study period, 45 patients with undiagnosed NoV were detected, whereas 50 patients were regularly diagnosed. The missed NoV cases were more frequently adults than children (80% versus 46%; P < 0.001). The viral load levels did not differ between the diagnosed and missed patients, but missed patients more frequently presented without diarrhea (20% versus 4%; P < 0.07). The newly admitted missed NoV cases with GE underwent more diagnostic imaging (24% versus 4%; P < 0.01) and tended to be hospitalized longer. When missed-NoV patients were included, the number of nosocomial clusters doubled and missed patients were index cases in 5 of the 6 clusters. These data indicate that NoV infections are frequently missed despite routine laboratory testing and demonstrate that underdiagnosis of NoV patients is associated with costly abdominal imaging and nosocomial clustering. Awareness of NoV infection in adult patients and education about the importance of viral GE should be increased. N oroviruses (NoVs) have emerged as the one of the most important pathogens causing acute gastroenteritis (GE) in children and adults (8,12). Nursing homes and hospitals are widely confronted with NoV outbreaks. Additionally, isolated (sporadic) cases of NoV frequently occur, but their incidence and clinical impact in hospitals have not been studied systematically (2, 17). Sporadic cases of NoV may result both from community-acquired infections in newly admitted patients and from nosocomial transmissions between patients, personnel, or visitors (9). Although sensitive commercial and homemade diagnostic assays for NoV have become widely available, sporadic NoV infections in hospitalized patients remain underdiagnosed, increasing the clinical burden and potential for nosocomial spread (1, 3, 21). Underrecognition of NoV may result in the individual patient undergoing more diagnostic procedures and may increase the influx of infectious patients into hospital wards, where they may trigger outbreaks (5, 14). Underdiagnosis of NoV may result from a referral bias, as well as from suboptimal laboratory facilities and inadequate specimen collection. This bias may occur when physicians selectively refer GE patients for bacteriological or parasitological testing but not virological testing. In the present study, we prosp...

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“…Indistinguishable genotypes of norovirus from ward surfaces and patients have been reported, with viable virus apparently surviving enhanced cleaning (119). One recent study identified norovirus reservoirs from expected sites near bathroom showers and toilets, but ward-based screening also demonstrated viral contamination of near-patient sites and a wide range of clinical equipment, including blood pressure and pulse oximeter machines, thermometers, notes trolleys, and even soap and alcohol gel containers.…”

Section: Norovirusmentioning

confidence: 99%

“…Persistent viral reservoirs place new admissions at continued risk of norovirus acquisition. Indeed, overloaded health care facilities may experience prolonged outbreaks, especially if confronted with a higher throughput of patients lacking prior exposure (119).…”

Section: Norovirusmentioning

confidence: 99%

Controlling Hospital-Acquired Infection: Focus on the Role of the Environment and New Technologies for Decontamination

2014

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SUMMARY There is increasing interest in the role of cleaning for managing hospital-acquired infections (HAI). Pathogens such as vancomycin-resistant enterococci (VRE), methicillin-resistant Staphylococcus aureus (MRSA), multiresistant Gram-negative bacilli, norovirus, and Clostridium difficile persist in the health care environment for days. Both detergent- and disinfectant-based cleaning can help control these pathogens, although difficulties with measuring cleanliness have compromised the quality of published evidence. Traditional cleaning methods are notoriously inefficient for decontamination, and new approaches have been proposed, including disinfectants, steam, automated dispersal systems, and antimicrobial surfaces. These methods are difficult to evaluate for cost-effectiveness because environmental data are not usually modeled against patient outcome. Recent studies have reported the value of physically removing soil using detergent, compared with more expensive (and toxic) disinfectants. Simple cleaning methods should be evaluated against nonmanual disinfection using standardized sampling and surveillance. Given worldwide concern over escalating antimicrobial resistance, it is clear that more studies on health care decontamination are required. Cleaning schedules should be adapted to reflect clinical risk, location, type of site, and hand touch frequency and should be evaluated for cost versus benefit for both routine and outbreak situations. Forthcoming evidence on the role of antimicrobial surfaces could supplement infection prevention strategies for health care environments, including those targeting multidrug-resistant pathogens.

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Norovirus in the hospital setting: virus introduction and spread within the hospital environment

Cited by 80 publications

References 21 publications

Norovirus GII.4 Detection in Environmental Samples from Patient Rooms during Nosocomial Outbreaks

Norovirus GII.4 Detection in Environmental Samples from Patient Rooms during Nosocomial Outbreaks

Unrecognized Norovirus Infections in Health Care Institutions and Their Clinical Impact

Controlling Hospital-Acquired Infection: Focus on the Role of the Environment and New Technologies for Decontamination

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