Impact of non-pharmaceutical interventions during the COVID-19 pandemic on pathogens transmitted via food in the Netherlands.

The COVID-19 pandemic impacted the transmission of many pathogens. The aim was to determine the effect of non-pharmaceutical interventions on the incidence of diseases transmitted via food. Weekly incidence rates for nine foodborne pathogens were collected from national surveillance registries. Weekly pathogen incidence during lockdown weeks of 2020 and 2021 were compared with corresponding weeks in 2015-2019. The same analyses were performed to determine the effect of self-defined expected impact levels of measures (low, intermediate and high). Eight out of 9 diseases showed a significant decrease in case number in 2020, except for listeriosis, which remained unchanged. The largest decrease was observed for rotavirus gastronteritis A (-81%), norovirus gastroenteritis (-78%), hepatitis A (-75%) and shigellosis (-72). In 2021, lower case numbers were observed for 6 out of 9 diseases compared with 2015-2019, with the largest decrease for shigellosis (-5/%) and hepatitis E (-47%). No significant change was observed for listeriosis, STEC infection and rotavirus gastroenteritis. Overall, measures with increased expected impact level did not result in a larger decrease in number of cases, except for Campylobacter, and norovirus and rotavirus gastroenteritis. Disease transmitted via food significantly decreased during the COVID-19 pandemic, with a more pronounced effect during 2020 than 2021.

Evaluation of inhibitory activity of essential oils and natural extracts on foodborne viruses.

AIMS: Enteric viruses are recognized as a major concern in health care and in the food sector in Canada. Novel clean-label strategies for controlling enteric viruses are sought in the food industry. In this study, we examined the antiviral potential of plant extracts and essential oils on murine norovirus 1 (MNV-1), hepatitis A virus (HAV), and herpes simplex virus 1 (HSV-1). METHODS AND RESULTS: Inactivation of the viruses by grape seed, blueberry, green tea, and cranberry extracts and by rosemary and thyme essential oils was measured using plaque formation assay. Concentrations ranging from 50 to 200 000 ppm with a contact time of 90 min were tested. Grape seed extract at 10 000 ppm was the most effective (P < 0.05) at reducing MNV-1 and HAV infectious titers, respectively, by 2.85 ± 0.44 log10 and 1.94 ± 0.17 log10. HSV-1 titer was reduced by 3.81 ± 0.40 log10 at 1000 ppm grape seed extract. CONCLUSIONS: Among the plant products tested, grape seed extract was found the most effective at reducing the infectious titers of MNV-1, HAV, and HSV.

Comprehensive analysis of predominant pathogenic bacteria and viruses in seafood products.

Given the growing global demand for seafood, it is imperative to conduct a comprehensive study on the prevalence and persistence patterns of pathogenic bacteria and viruses associated with specific seafood varieties. This assessment thoroughly examines the safety of seafood products, considering the diverse processing methods employed in the industry. The importance of understanding the behavior of foodborne pathogens, such as Salmonella typhimurium, Vibrio parahaemolyticus, Clostridium botulinum, Listeria monocytogenes, human norovirus, and hepatitis A virus, is emphasized by recent cases of gastroenteritis outbreaks linked to contaminated seafood. This analysis examines outbreaks linked to seafood in the United States and globally, with a particular emphasis on the health concerns posed by pathogenic bacteria and viruses to consumers. Ensuring the safety of seafood is crucial since it directly relates to consumer preferences on sustainability, food safety, provenance, and availability. The review focuses on assessing the frequency, growth, and durability of infections that arise during the processing of seafood. It utilizes next-generation sequencing to identify the bacteria responsible for these illnesses. Additionally, it analyzes methods for preventing and intervening of infections while also considering the forthcoming challenges in ensuring the microbiological safety of seafood products. This evaluation emphasizes the significance of the seafood processing industry in promptly responding to evolving consumer preferences by offering current information on seafood hazards and future consumption patterns. To ensure the continuous safety and sustainable future of seafood products, it is crucial to identify and address possible threats.

A robust human norovirus replication model in zebrafish larvae.

Human noroviruses (HuNoVs) are the most common cause of foodborne illness, with a societal cost of $60 billion and 219,000 deaths/year. The lack of robust small animal models has significantly hindered the understanding of norovirus biology and the development of effective therapeutics. Here we report that HuNoV GI and GII replicate to high titers in zebrafish (Danio rerio) larvae; replication peaks at day 2 post infection and is detectable for at least 6 days. The virus (HuNoV GII.4) could be passaged from larva to larva two consecutive times. HuNoV is detected in cells of the hematopoietic lineage and the intestine, supporting the notion of a dual tropism. Antiviral treatment reduces HuNoV replication by >2 log10, showing that this model is suited for antiviral studies. Zebrafish larvae constitute a simple and robust replication model that will largely facilitate studies of HuNoV biology and the development of antiviral strategies.

Predominance of Human Bocavirus Genotypes 1 and 2 in Oysters in Thailand.

Human bocavirus (HBoV) has been recognized as an important pathogen that causes respiratory infection and acute gastroenteritis in young children worldwide. HBoV is most likely transmitted by the respiratory route and by fecal-oral transmission. Recently, HBoV has been detected in several types of environmental water and in bivalve shellfish. However, study of the existence of HBoV in oysters is still undocumented in Thailand. In this study, 144 oyster samples collected from different markets in Chiang Mai, Thailand, in 2017 and 2018 were investigated for the presence of HBoV by nested PCR and sequencing. HBoV was detected in 11 out of 144 samples (7.6%). Nine HBoV-positive samples (81.8%) were identified as genotype 1 (HBoV1) and two (18.2%) as HBoV2. A monthly investigation of HBoV in oyster samples from July 2017 to June 2018 showed that HBoV was sporadically detected in particular months spanning the rainy and colder season, with a peak in January. This study demonstrates the presence and genotype diversity of HBoV in oyster samples in Thailand. The findings contribute to evaluating the risk of foodborne transmission of HBoV and to monitoring outbreaks of HBoV in Thailand and in other countries. IMPORTANCE Human bocavirus is recognized as an important cause of respiratory infection and of acute gastroenteritis in children worldwide. Human bocavirus has been widely detected in many clinical specimens, as well as in several types of environmental samples. Most previous studies describe the incidence of bocavirus infection in humans, whereas few data are available for the occurrence of human bocavirus in food materials, particularly that in bivalve shellfish. Our findings provide evidence for the existence and prevalence of human bocavirus in oysters, suggesting that further monitoring of the potential risk of food- and waterborne transmission of this virus to humans should be undertaken.

Exploring the potential of foodborne transmission of respiratory viruses.

The ongoing pandemic involving severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has raised the question whether this virus, which is known to be spread primarily though respiratory droplets, could be spread through the fecal-oral route or via contaminated food. In this article, we present a critical review of the literature exploring the potential foodborne transmission of several respiratory viruses including human coronaviruses, avian influenza virus (AVI), parainfluenza viruses, human respiratory syncytial virus, adenoviruses, rhinoviruses, and Nipah virus. Multiple lines of evidence, including documented expression of receptor proteins on gastrointestinal epithelial cells, in vivo viral replication in gastrointestinal epithelial cell lines, extended fecal shedding of respiratory viruses, and the ability to remain infectious in food environments for extended periods of time raises the theoretical ability of some human respiratory viruses, particularly human coronaviruses and AVI, to spread via food. However, to date, neither epidemiological data nor case reports of clear foodborne transmission of either viruses exist. Thus, foodborne transmission of human respiratory viruses remains only a theoretical possibility.

Magnolia officinalis and Its Honokiol and Magnolol Constituents Inhibit Human Norovirus Surrogates.

Norovirus is a major cause of foodborne disease and nonbacterial gastroenteritis globally. This study evaluated the antiviral effects of Magnolia officinalis extract and its honokiol and magnolol constituents against human norovirus surrogates, murine norovirus (MNV) and feline calicivirus (FCV) in vitro, and in model food systems. Pretreatment or cotreatment of M. officinalis extract at 1 mg/mL reduced MNV and FCV titers by 0.6-1.8 log. Honokiol and magnolol, which are the major polyphenols in the extract, showed significant antiviral effects against MNV and FCV. The virus-infected cells that were treated with M. officinalis extract exhibited significantly increased glutathione levels (p < 0.05). The extract, honokiol, and magnolol revealed ferric ion-reducing and 2,2-diphenyl-1-picrylhydrazyl radical scavenging activities in a dose-dependent manner. Furthermore, MNV and FCV titers were reduced by >1.6 log or to undetectable levels in apple, orange, and plum juices and by 0.9 and 1.6 log in milk, respectively, when they were treated with the extract at 5 mg/mL. Therefore, the present study suggests that M. officinalis extract can be used as an antiviral food material to control norovirus foodborne diseases.

Hepatitis A infections from food.

Food contaminated by hepatitis A virus (HAV) is responsible of the 2-7% of all HAV outbreaks worldwide. This review provides a description of the HAV characteristics, its infectivity and epidemiological features. In addition, this review compiles existing original papers reporting HAV prevalence, viral titres in foodstuffs and the risk associated with food contamination. The purpose of this revision is to conduct a structured and systematic review of the published molecular procedures for HAV detection in food, including the assessment of its infectivity.

Virological analyses in collective catering outbreaks in France between 2012 and 2017.

Enteric viruses cause the majority of foodborne illnesses and common symptoms of many foodborne illnesses include vomiting, diarrhea, abdominal pain, and fever. Among the enteric viruses, human Norovirus (NoV) and hepatitis virus (HAV and HEV) are the main viruses suspected to cause foodborne outbreaks and represent a serious public health. The study presents survey tools of viruses in a wide variety of foodstuffs and results obtained during 56 foodborne outbreaks investigation in France between 2012 and 2017. 246 suspected foods were examined for the presence of four human enteric viruses (NoV GI and NoV GII, HAV or HEV) either using methods described in the EN ISO 15216-1 or in house methods. All viral analysis of food samples were performed with the implementation of process control and an external amplification controls. Eighteen of 56 foodborne outbreaks investigated included at least one positive food sample (16/18 NoV, 1/18 HAV and 1/18 HEV). The genomic levels of four viruses detected ranged from < 102 to 107 genome copies per g or per L. This study showed the interest to develop methods for the extraction of viruses in different foodstuffs to increase the possibility to identify the association between viral illness and food consumption.

Assessment of transmission risk in WSSV-infected shrimp Litopenaeus vannamei upon cooking.

White spot syndrome virus has been a threat to the global shrimp industry since it was discovered in Taiwan in 1992. Thus, shrimp-producing countries have launched regulations to prevent import of WSSV-infected commodity shrimp from endemic areas. Recently, cooked shrimp that is infected with WSSV tested positive by PCR. However, there is no study to determine the infectivity of WSSV in cooked shrimp that tested positive by PCR. In the present study, WSSV-infected shrimp were cooked at boiling temperature for different times including 0, 1, 3, 5, 10 and 30 min. Upon exposure to boiling temperature, WSSV-infected shrimp were fed to SPF shrimp (Litopenaeus vannamei). The result showed experimentally challenged shrimp from 0-min treatment (positive control) indeed got infected with WSSV. However, experimentally challenged shrimp that were fed tissues boiled at 1, 3, 5, 10 and 30 min were not infected with WSSV. Mortality data showed that only the positive control (0-min) treatment displayed high mortality, whereas no mortality was observed in any other treatment category. These findings suggest that cooking shrimp at boiling temperature for at least 1 min might prevent any potential spread of WSSV from endemic countries to other geographical areas where WSSV has not yet been reported.

Resurgence of an international hepatitis A outbreak linked to imported frozen strawberries, Germany, 2018 to 2020.

Following outbreaks linked to frozen strawberries in Sweden and Austria in 2018, 65 cases linked to the same hepatitis A virus strain were detected in Germany between October 2018 and January 2020, presenting in two waves. Two case-control studies and a comparison of cases' consumption frequencies with purchase data from a large consumer panel provided strong evidence for frozen strawberry cake as the main vehicle of transmission. Of 46 cases interviewed, 27 reported consuming frozen strawberry cake and 25 of these identified cake(s) from brand A spontaneously or in product picture-assisted recall. Trace back investigations revealed that the Polish producer involved in the previous outbreaks in Sweden and Austria had received frozen strawberries from Egypt via a wholesaler that also delivered frozen strawberries to manufacturer of brand A. Phylogenetic analyses linked the outbreak strain to similar strains formerly isolated from sewage, stool and strawberries in Egypt. Complete trace back and timely recall of products with strong evidence of contamination is important to control an outbreak and prevent later resurgence, particularly for food items with a long shelf life. Continued molecular surveillance of hepatitis A is needed to identify outbreaks and monitor the success of food safety interventions.

Large concomitant outbreaks of acute gastroenteritis emergency visits in adults and food-borne events suspected to be linked to raw shellfish, France, December 2019 to January 2020.

On 27 December 2019, the French Public Health Agency identified a large increase in the number of acute gastroenteritis and vomiting visits, both in emergency departments and in emergency general practitioners' associations providing house-calls. In parallel, on 26 and 27 December, an unusual number of food-borne events suspected to be linked to the consumption of raw shellfish were reported through the mandatory reporting surveillance system. This paper describes these concomitant outbreaks and the investigations' results.

Describing the Epidemiology of Foodborne Outbreaks in New South Wales from 2000 to 2017.

Foodborne disease causes an estimated 4.1 million cases of illness in Australia each year and is responsible for causing many significant common source outbreaks. We analyzed 18 years of foodborne outbreak data collected in New South Wales (NSW), and classified the likely pathogen type responsible for outbreaks of unknown etiology, to track broad trends over time. A total of 869 outbreaks were reported in NSW from 2000 to 2017. The majority (53%) of outbreaks did not have a pathogen identified and underwent pathogen type categorization based on the epidemiology of the outbreak. The proportion of outbreaks due to toxin producing bacteria decreased over time, whereas the proportion of outbreaks due to other bacterial pathogens increased. The proportion of outbreaks due to viral gastroenteritis pathogens had no overall changing trend over time. Bacterial outbreaks had significantly more identified cases and had more hospitalizations than other pathogen type causes. Other features associated with high case numbers, hospitalizations, and deaths in foodborne outbreaks included being due to food contaminated in primary production, involving consumption of raw products, and having evidence of poor sanitation in the food preparation areas. Eggs were the most commonly determined pathogen food source, occurring in 12% of outbreaks; however, most outbreak investigations (77%) did not have a pathogen food source identified. This analysis demonstrates a changing landscape of foodborne outbreaks over time. Increases in outbreaks due to bacterial and viral pathogens coincide with increases in sporadic notifications of the same pathogens, whereas decreases in toxin caused outbreaks followed the introduction of mandatory food safety training in retail food businesses. Recognizing issues in food production and implementing improvements that reduce the number of pathogens in food will be key to reducing the incidence of foodborne outbreaks.

[Etiology and epidemiological characteristics of gastroenteritis virus in food-borne diarrhea from three cities in Shandong Province, 2017].

Objective: To analyze the etiology and epidemiological characteristics of gastroenteritis virus in foodborne diseases from three cities in Shandong. Methods: From January to December 2017, six sentinel hospitals in Jinan, Yantai and Linyi city of Shandong Province were selected as the research sites. Stool samples of 1 397 diarrhea patients were collected, as well as basic information and clinical symptoms. Duplex quantitative RT-PCR was used to detect Norovirus genogroupⅠ (Nov GⅠ) and genogroupⅡ (Nov GⅡ), Sapovirus (SAV) and Human astrovirus (HAstV), respectively, quantitative RT-PCR was used to detect group A Rotavirus (RVA), and quantitative PCR was used to detect Enteric adenovirus (EAdV). The specific gene of the virus were sequenced and typed. It was compared that the gastroenteritis virus rate in cases with different characteristics and the clinical symptoms difference between the virus positive and negative cases. Results: The median age (P(25), P(75)) was 23 (1, 42) , mainly male, 57.48% with 803 cased and children under 5 years old, 36.36% with 508 cases. The positive rate of gastroenteritis virus was 33.93% (474 cases), and that of Jinan, Linyi and Yantai City were 32.03% (147/459), 41.54% (189/455) and 28.57% (138/483), respectively (P<0.001). Nov GⅡ had the highest positive rate, 16.54% (231 cases), which, mainly GⅡ.P16/GⅡ.2 (48.28%, 56/116), peaked in May (24.75%, 50/202) and June (19.59%, 38/194). In patients of gastroenteritis virus positive, 44.51% (211/474) had vomiting symptoms, higher than that of patients of gastroenteritis virus negative (34.13%, 315/923). The difference was statistically significant (P<0.001). Conclusion: In Shandong Province, the majority of gastroenteritis patients were male and children under 5 years old. Nov GⅡ possessed highest epidemic intensity, and peaked in spring and summer. Viral gastroenteritis had atypical clinical symptoms.

Incidence of hepatitis E virus infection among blood donors in a high endemic area of Central Italy.

In Europe, autochthonous hepatitis E virus (HEV) infection is mainly a foodborne zoonosis, but it is also transmitted by blood transfusion. Despite the numerous prevalence surveys, only a few studies have investigated HEV incidence. We aimed to determine HEV incidence and risk factors among blood donors in a hyperendemic area in Central Italy. Of 296 blood donors who had tested HEV negative in two previous seroprevalence surveys in L'Aquila, 198 agreed to undergo at least another blood sampling for estimating HEV incidence nearly 2 years after the prevalence surveys. Ten newly acquired infections were detected, yielding an overall incidence of 2.1/100 person-years (95%CI: 1.0-3.9), with an estimated participant's cumulative probability of becoming HEV infected of 6.5% (95%CI: 3.5-12.0) at 4 years after enrolment. Seven newly infected blood donors were IgG positive only, two were IgM positive (one also IgG positive) and one was HEV RNA positive only, harbouring subtype 3c. Incident infection was most strongly associated with eating game meat, raw-dried pork liver sausage and raw-dried wild boar sausage. None of these exposures was statistically significant, even if eating raw-dried wild boar sausage approached significance (P = 0.06). The HEV incidence we found was considerable compared with other similar studies. The nearly significant association of incident infection with wild boar and other game meat consumption was in agreement with the 3c subtype isolation in the viremic donor. However, beyond eating habits, also other exposure sources are likely important in hyperendemic areas, where incidence and risk exposure studies need to be undertaken for effectively preventing HEV transmission.

GII.17 norovirus infections in outbreaks of acute nonbacterial gastroenteritis in Osaka City, Japan during two decades.

Norovirus (NoV) is a major cause of viral gastroenteritis, and GII.4 has been the predominant genotype worldwide since the mid-1990s. During the 2014 to 2015 winter, a rare genotype, NoV GII.17, emerged and became prevalent mainly in East Asia. Over the past two decades, NoV molecular surveillance in Osaka City, Japan, has revealed that NoV GII.17 was detected for the first time in February 2001 and that NoV GII.17-associated outbreaks remarkably increased during the 2014 to 2015 season, with higher incidence recorded in January to March 2015. Genetic analysis indicated that 28 GII.17 outbreak strains were closely related to the novel GII.P17-GII.17 variants represented by the Kawasaki308/2015/JP strain, similar to that in other regions. Statistical analysis showed that NoV GII.17 infections were more common in adults than GII.3 and GII.4 infections, suggesting that the affected adults most likely did not have antibodies against NoV GII.17 and the novel GII.17 variant had recently appeared. Regarding transmission, food was one of the most important factors involved in the spread of NoV GII.17 among adults; 61% of GII.17 outbreaks were foodborne, with oysters being the most common vehicle. Interplay between pathogens, hosts, and environmental factors was considered to be important in the 2014 to 2015 NoV GII.17 epidemic.

Multi-phased internalization of murine norovirus (MNV) in Arabidopsis seedlings and its potential correlation with plant defensive responses.

Norovirus is a highly infectious human pathogen that causes acute foodborne diseases worldwide. As global diet patterns have begun to incorporate a higher consumption of fresh agricultural products, the internalization of norovirus into plants has emerged as a potential threat to human health. Here, we demonstrated that murine norovirus (MNV1) was internalized into Arabidopsis in multiple phases, and this internalization was correlated with Arabidopsis innate immunity responses. Under hydroponic conditions, continuous treatment of MNV1 retarded root growth and facilitated flower development of Arabidopsis without causing necrotic lesions. Examination of viral titers and RNA levels revealed that MNV1 was internalized into Arabidopsis in at least three different phases. In response to MNV1 treatment, the Arabidopsis defensive marker PR1 (a salicylic acid signaling marker) was transiently up-regulated at the early stage. PDF1.2, a jasmonic acid signaling marker, exhibited a gradual induction over time. Noticeably, Arabidopsis RNS1 (T2 ribonuclease) was rapidly induced by MNV1 and exhibited anti-correlation with the internalization of MNV1. Exposure to recombinant Arabidopsis RNS1 protein reduced the viral titers and degraded MNV1 RNA in vitro. In conclusion, the internalization of MNV1 into Arabidopsis was fluctuated by mutual interactions that were potentially regulated by Arabidopsis immune systems containing RNS1.

Foodborne viral outbreaks associated with frozen produce.

Over the past decade, frozen fruits have been a major vehicle of foodborne illnesses mainly attributed to norovirus (NoV) and hepatitis A virus (HAV) infections. Fresh produce may acquire viral contamination by direct contact with contaminated surface, water or hands, and is then frozen without undergoing proper decontamination. Due to their structural integrity, foodborne viruses are able to withstand hostile conditions such as desiccation and freezing, and endure for a long period of time without losing their infectivity. Additionally, these foods are often consumed raw or undercooked, which increases the risk of infection. Herein, we searched published literature and databases of reported outbreaks as well as the databases of news articles for the viral outbreaks associated with the consumption of frozen produce between January 2008 and December 2018; recorded the worldwide distribution of these outbreaks; and analysed the implication of consumption of different types of contaminated frozen food. In addition, we have briefly discussed the factors that contribute to an increased risk of foodborne viral infection following the consumption of frozen produce. Our results revealed that frozen fruits, especially berries and pomegranate arils, contributed to the majority of the outbreaks, and that most outbreaks were reported in industrialised countries.

Estimate of the annual burden of foodborne illness in nondeployed active duty US Army Service Members: five major pathogens, 2010-2015.

In this study, we estimate the burden of foodborne illness (FBI) caused by five major pathogens among nondeployed US Army service members. The US Army is a unique population that is globally distributed, has its own food procurement system and a food protection system dedicated to the prevention of both unintentional and intentional contamination of food. To our knowledge, the burden of FBI caused by specific pathogens among the US Army population has not been determined. We used data from a 2015 US Army population survey, a 2015 US Army laboratory survey and data from FoodNet to create inputs for two model structures. Model type 1 scaled up case counts of Campylobacter jejuni, Shigella spp., Salmonella enterica non-typhoidal and STEC non-O157 ascertained from the Disease Reporting System internet database from 2010 to 2015. Model type 2 scaled down cases of self-reported acute gastrointestinal illness (AGI) to estimate the annual burden of Norovirus illness. We estimate that these five pathogens caused 45 600 (5%-95% range, 30 300-64 000) annual illnesses among nondeployed active duty US Army Service members. Of these pathogens, Norovirus, Campylobacter jejuni and Salmonella enterica non-typhoidal were responsible for the most illness. There is a tremendous burden of AGI and FBI caused by five major pathogens among US Army Soldiers, which can have a tremendous impact on readiness of the force. The US Army has a robust food protection program in place, but without a specific active FBI surveillance system across the Department of Defence, we will never have the ability to measure the effectiveness of modern, targeted, interventions aimed at the reduction of specific foodborne pathogens.

A foodborne outbreak of gastroenteritis caused by Norovirus and Bacillus cereus at a university in the Shunyi District of Beijing, China 2018: a retrospective cohort study.

BACKGROUND: On September 4, 2018, a boarding school in the Shunyi District of Beijing, China reported an outbreak of acute gastroenteritis. At least 209 suspected students caused of diarrhea and vomiting. The case was investigated, and control measures were taken to prevent further spread. METHODS: A retrospective cohort study was conducted among the school students and staff in order to test hypothesis that high risk of food served at the school canteen. We collected information on demographics, refectory records, person to person transmission by uniform epidemiological questionnaire. Risk ratios (RR) and 95% confidence intervals (CI) were calculated. Stool specimens of cases and canteen employees, retained food, water, and environmental swabs were investigated by laboratory analysis. RESULTS: We identified 209 cases (including 28 laboratory-confirmed cases) which occurred from August 29 to September 10. All cases were students, and the average age was 20, 52% were male. The outbreak lasted for 13 days, and peaked on September 5. Consumption of Drinks stall and Rice flour stall on September 1 (RR:3.4, 95%CI:1.5-7.8, and RR:7.6, 95%CI:2.8-20.2), Rice flour stall and Fish meal stall on September 2 (RR:4.0, 95%CI:1.2-13.6, and RR:4.6, 95%CI:1.7-12.5), muslim meal stall on September 4 (RR:2.7, 95%CI:1.3-5.4), Barbeque stall on September 5 (RR:3.0, 95%CI:1.2-7.0) were independently associated with increased risk of disease within the following 2 days. Among 35 specimens of rectal swabs or feces from students, 28 specimens were positive. Norovirus GI.6 alone was detected in 23 specimens, Bacillus cereus alone in 3 specimens and both norovirus GI.6 and Bacillus cereus in 2 specimens. Ten specimens of rectal swabs from canteen employees were positive for norovirus GI, and 2 specimens were positive for Bacillus cereus. Four retained food specimens were positive for Bacillus cereus, and environmental samples were negative for any viruses or bacteria. CONCLUSION: Our investigation indicated that canteen employees were infected by two pathogens (norovirus and Bacillus cereus) and transmission may have been possible due to unhygienic practices. Student consumption of food or drink at high-risk stalls was determined as the probable cause of the outbreak.