An integrated approach to identifying international foodborne norovirus outbreaks.

International foodborne norovirus outbreaks can be difficult to recognize when using standard outbreak investigation methods. In a novel approach, we provide step-wise selection criteria to identify clusters of outbreaks that may involve an internationally distributed common foodborne source. After computerized linking of epidemiologic data to aligned sequences, we retrospectively identified 100 individually reported outbreaks that potentially represented 14 international common source events in Europe during 1999-2008. Analysis of capsid sequences of outbreak strains (n = 1,456), showed that ≈7% of outbreaks reported to the Foodborne Viruses in Europe database were part of an international event (range 2%-9%), compared with 0.4% identified through standard epidemiologic investigations. Our findings point to a critical gap in surveillance and suggest that international collaboration could have increased the number of recognized international foodborne outbreaks. Real-time exchange of combined epidemiologic and molecular data is needed to validate our findings through timely trace-backs of clustered outbreaks.

Unspecified gastroenteritis illness and deaths in the elderly associated with norovirus epidemics.

BACKGROUND: New variant strains of norovirus have emerged worldwide in recent years, evolving by mutation much like influenza viruses. These strains have been associated with a notable increase in the number of annual norovirus outbreaks. However, the impact of such increased norovirus activity on morbidity and mortality is not clear because norovirus infection is rarely specifically registered. METHODS: We studied trends of gastroenteritis with unspecified cause in medical registrations (ie, general practitioner [GP] visits, hospitalizations, and deaths) and their association with known temporal trends in norovirus outbreaks in the Netherlands. Using weekly counts in the elderly (aged 65+ years) from 1999 through 2006, we applied Poisson regression analyses adjusted for additional pathogens and seasonal trends (linear, sine, and cosine terms). RESULTS: In the elderly, each notified norovirus outbreak was associated with an estimated 26 unspecified gastroenteritis GP visits (95% confidence interval = 17-34), 2.2 unspecified gastroenteritis hospitalizations (1.6-2.7), and 0.14 unspecified gastroenteritis deaths (0.08-0.21). For the heaviest norovirus season (2004-2005), these models attributed up to 3804 unspecified gastroenteritis GP visits, 318 unspecified gastroenteritis hospitalizations, and 21 unspecified gastroenteritis deaths to norovirus outbreaks among a total elderly population of 2.3 million. DISCUSSION: The recent increase in norovirus outbreak activity is associated with increases of unspecified gastroenteritis morbidity and even deaths in the elderly. Norovirus should not be regarded as an infection with trivial health risks.

Epidemiology and genotype analysis of emerging sapovirus-associated infections across Europe.

Sapoviruses (SaVs) belong to the Caliciviridae family and can cause gastroenteritis in humans and swine. Despite extensive testing, human sapoviruses have been found only in sporadic cases and in one mixed outbreak in children between 1994 and 2007 in the Netherlands. Here we describe a change in sapovirus epidemiology in the Netherlands resulting in sapovirus outbreaks and infections in adults. From November 2007 to January 2009, 478 outbreaks of acute gastroenteritis were reported to the National Institute for Public Health and the Environment in the Netherlands as a part of ongoing surveillance. Sapoviruses were found to be the most likely cause of 19 outbreaks (4%). During the same 2-year period, sapovirus infections were reported in Sweden, Slovenia, and Hungary. In the Netherlands, further characterization of outbreak strains showed that 12 (63%) sapovirus outbreaks were caused by genotype I.2 viruses. Most patients were adults older than 60 years (range, 1 to 100 years). Phylogenetic analysis using all presently available SaV sequences showed high homology between genotype I.2 strains detected in different geographical regions (Sweden, Slovenia, Taiwan, Japan, and Russia) since 2007. These first reported outbreaks of sapovirus infections in adults in the Netherlands were remarkable. Detection of identical genotypes in many samples might suggest that these viruses have the same origin, and since the infection is spreading fast, the prevalence of sapovirus infection may be increasing. The incidence of sapovirus infections in these countries suggests that a substantial part of Europe is affected by this virus.

Emergence of new norovirus variants on spring cruise ships and prediction of winter epidemics.

In June 2006, reported outbreaks of norovirus on cruise ships suddenly increased; 43 outbreaks occurred on 13 vessels. All outbreaks investigated manifested person-to-person transmission. Detection of a point source was impossible because of limited investigation of initial outbreaks and data sharing. The most probable explanation for these outbreaks is increased norovirus activity in the community, which coincided with the emergence of 2 new GGII.4 variant strains in Europe and the Pacific. As in 2002, a new GGII.4 variant detected in the spring and summer corresponded with high norovirus activity in the subsequent winter. Because outbreaks on cruise ships are likely to occur when new variants circulate, an active reporting system could function as an early warning system. Internationally accepted guidelines are needed for reporting, investigating, and controlling norovirus illness on cruise ships in Europe.