norovirus (Norwalk-like virus, winter vomiting disease)
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Introduction
Single-stranded RNA virus.
Epidemiology
- transmitted by fecal oral route
- most likely transmitted by contamination or food or water[2]
- low inoculum required to produce infection[10]
- persistence of virus on environmental surfaces[10]
- frequently detected in the air of healthcare facilities during outbreaks, even outside patients' rooms[9]
- second to the common cold as a cause of illness in the USA
- most common cause of gastroenteritis in USA
- only 10-100 organisms needed to cause infection
- highly contagious, associated with epidemic outbreaks
- GII.4 Sydney strain 2012[6]
- most common cause of gastroenteritis worldwide[4]
- cause of > 50% of foodborne gastroenteritis in the U.S.[2]
- 20% of gastroenteritis in children[7]
- 18% of gastroenteritis worldwide[8]
- case of norovirus peak in winter months
- viral shedding up to 2 weeks after symptom resolution[2]
- infection does not produce lasting immunity[4]
- norovirus outbreak at Grand Canyon affecting rafters & backpackers apparently transmitted via portable toilets[13]
- norovirus outbreaks in parts of U.S. & 3 cruise ships in December 2024[14]
- 1,894 passengers & 245 crew got sick with gastrointestinal symptoms on 16 Cruise ships in 2024 with norovirus accounting for 13 of the 16[14]
Pathology
Clinical manifestations
- incubation time is > 14 hours
- median incubation period of 24-48 hours[15]
- abrupt onset of symptoms
- vomiting is predominant symptom
- abdominal discomfort
- mild to moderate non-inflammatory diarrhea (watery diarrhea)
- fever (50%)
- headache
- after 1-2 days, most people start to improve[15]
- symptoms may persist for 48-72 hours
- dehydration may be life-threatening the young, elderly, immunocompromised
Laboratory
- RT-PCR for norvirus RNA in stool
- norovirus antigen in stool
- norovirus in stool by electron microscopy
- ELISA lacks sensitivity & specificity
Complications
- among nursing home residents
- 1 excess hospitalization for every 4 outbreaks
- 1 excess death for every 9 outbreaks[5]
- irritable bowel syndrome 12 months after infection (13%)
Management
- self-limiting disorder, no antiviral treatment[15]
- dehydration is a concern
- handwashing & surface sanitization are the cornerstones of infection control
- viral shedding up to 2 weeks after symptom resolution[2]; one month[15]
More general terms
More specific terms
References
- ↑ CDC, Division of viral diseases http://www.cdc.gov/ncidod/dvrd/revb/gastro/norovirus.htm
- ↑ Jump up to: 2.0 2.1 2.2 2.3 2.4 Medical Knowledge Self Assessment Program (MKSAP) 15, 17, 18, 19. American College of Physicians, Philadelphia 2009, 2015, 2018, 2021.
Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022 - ↑ Hall AJ et al Updated Norovirus Outbreak Management and Disease Prevention Guidelines MMWR March 4, 2011 / 60(RR03);1-15 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/21368741 <Internet> http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6003a1.htm
- ↑ Jump up to: 4.0 4.1 4.2 Journal Watch, Massachusetts Medical Society, June 14, 2012 http://www.jwatch.org (subscription required)
Repp KK, Keene WE. A point-source norovirus outbreak caused by exposure to fomites. J Infect Dis 2012 Jun 1; 205:1639 PMID: https://www.ncbi.nlm.nih.gov/pubmed/22573873
Hall AJ. Noroviruses: The perfect human pathogens? J Infect Dis 2012 Jun 1; 205:1622 PMID: https://www.ncbi.nlm.nih.gov/pubmed/22573872 - ↑ Jump up to: 5.0 5.1 Trivedi TK et al Hospitalizations and Mortality Associated With Norovirus Outbreaks in Nursing Homes, 2009-2010 JAMA. Oct 18, 2012 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/23079758 <Internet> http://jama.jamanetwork.com/article.aspx
- ↑ Jump up to: 6.0 6.1 Centers for Disease Control and Prevention Notes from the Field: Emergence of New Norovirus Strain GII.4 Sydney - United States, 2012 MMWR. January 25, 2013 / 62(03);55-55 http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6203a4.htm
- ↑ Jump up to: 7.0 7.1 Payne DC et al. Norovirus and medically attended gastroenteritis in U.S. children. N Engl J Med 2013 Mar 21; 368:1121. http://www.nejm.org/doi/full/10.1056/NEJMsa1206589
- ↑ Jump up to: 8.0 8.1 Ahmed SM, Hall AJ, Robinson AE et al Global prevalence of norovirus in cases of gastroenteritis: a systematic review and meta-analysis. The Lancet Infectious Diseases. Online June 27, 2014 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/24981041 <Internet> http://www.thelancet.com/journals/laninf/article/PIIS1473-3099%2814%2970767-4/abstract
- ↑ Jump up to: 9.0 9.1 Bonifait L, Charlebois R, Vimont A et al Detection and Quantification of Airborne Norovirus During Outbreaks in Healthcare Facilities. Clin Infect Dis. 2015 Aug 1;61(3):299-304 PMID: https://www.ncbi.nlm.nih.gov/pubmed/25900175
- ↑ Jump up to: 10.0 10.1 10.2 NEJM Knoweledge+ Question of the Week. Sept 4, 2018 https://knowledgeplus.nejm.org/question-of-week/589/
- ↑ Glass RI, Parashar UD, Estes MK. Norovirus gastroenteritis. N Engl J Med. 2009 Oct 29;361(18):1776-85 PMID: https://www.ncbi.nlm.nih.gov/pubmed/19864676 Free PMC Article https://www.nejm.org/doi/full/10.1056/NEJMra0804575
- ↑ Estes MK et al. Noroviruses everywhere: has something changed?. Curr Opin Infect Dis 2006 Aug 31; 19:467 PMID: https://www.ncbi.nlm.nih.gov/pubmed/1694087
- ↑ Jump up to: 13.0 13.1 Phillips J. CDC: 222 People at the Grand Canyon Got Sick With 'Explosive' Symptoms. The Epoch Times. Sept 30, 2022 https://www.theepochtimes.com/cdc-222-people-at-the-grand-canyon-got-sick-with-explosive-symptoms_4766488.html
- ↑ Jump up to: 14.0 14.1 14.2 Snow D Norovirus cases are surging in parts of the US, CDC data shows AP News. Dec 28, 2024 https://apnews.com/article/norovirus-outbreak-stomach-virus-78e4a5f3c55d0af68f0c9e115c2369e5
AMA Morning Report. Jan 2, 2025 American Medical Association
CDC Vessel Sanirrion Program (VSP) Dec 31, 2024 Outbreaks on Cruise Ships in VSP's Jurisdiction https://www.cdc.gov/vessel-sanitation/cruise-ship-outbreaks/index.html - ↑ Jump up to: 15.0 15.1 15.2 15.3 15.4 15.5 Sax PE Ten Interesting Things About Norovirus Worth Knowing. NEJM Journal Watch. HIV and ID Observations. Jan 11, 2025 https://blogs.jwatch.org/hiv-id-observations/index.php/ten-interesting-things-about-norovirus-worth-knowing/2025/01/11/