- Email: [email protected]
Gastroenteritis outbreak caused by norovirus associated with the children's club of a hotel located in Majorca, Spain
Research Notes
CMI
with the study of Hubschen et al. (Table 1). Tentative A7 strains showed less than 4% nucleotide divergence when compared with A1, and particularly with A3, A4 and A5. Similar results were obtained when tentative A7 was compared with quasi-subgenotype A3 (according to the recent proposed classification). We believe that a few selected strains as reference sequences are not representative of the nucleotide divergence because we obtained different results when analysing all available strains. Subgenotypes A1, A2 and A4 (previously known as A6) can be considered as definite ‘subgenotypes’, because they form clear phylogenetic clusters supported by high bootstrap values (Fig. 1), with considerable divergence in mean genetic distances. In conclusion, our analysis demonstrated that the introduced strains ‘tentative subgenotype A7’ did not meet the ‘subgenotype’ definition according to genetic distance and topology of phylogeny tree. Therefore, we propose that these strains should be also considered as new members of quasi-subgenotype A3. Moreover, their close evolutionary relationship with A3 is consistent with the geographical origins of the strains [2]. This finding highlights our hypothesis that geographical origin may have a key role in further classification of HBV subgenotypes [3]. In addition, it underscores the arguments of Schaefer et al. [4] on the roles of the International Committee on Taxonomy of Viruses (ICTV) as well as those of experts in HBV subgenotyping. Finally, we would like to stress again that the introduction of a new HBV genotype and especially a subgenotype should adhere to clear rules to avoid misclassification and confusion.
949
4. Schaefer S, Magnius L, Norder H. Under construction: classification of hepatitis B virus genotypes and subgenotypes. Intervirology 2009; 52: 323–325. 5. Kramvis A, Kew M, Francois G. Hepatitis B virus genotypes. Vaccine 2005; 23: 2409–2423. 6. Kramvis A, Arakawa K, Yu MC, Nogueira R, Stram DO, Kew MC. Relationship of serological subtype, basic core promoter and precore mutations to genotypes/subgenotypes of hepatitis B virus. J Med Virol 2008; 80: 27–46.
Gastroenteritis outbreak caused by norovirus associated with the children’s club of a hotel located in Majorca, Spain A. Dome´nech-Sa´nchez1,2 1) Saniconsult Ibe´rica SL, Palma de Mallorca and 2) A´rea de Microbiologı´a and Instituto Universitario de Investigacio´n en Ciencias de la Salud (IUNICS), Universidad de las Islas Baleares, Palma de Mallorca, Spain
Abstract A possible gastroenteritis outbreak in a hotel located in northern Majorca was reported on June 2009. The subsequent investigation revealed a total of 14 cases with onset of symptoms from 18 June to 26 June. Symptoms affected mainly the children, their parents and the staff related to the children’s club; a vomiting episode was described at the beginning of the outbreak. Genotype 2 norovirus was detected in stool samples, demonstrating its role as the aetiological agent. The special hygienic measures implemented allowed the outbreak to be controlled.
Transparency Declaration This study was co-funded by the institute for the Promotion of Innovation by Science and Technology in Flanders (strategic basic research project SIMID). All authors declare that they have no conflicts of interest.
Keywords: Children, gastroenteritis, hotel, norovirus, outbreak Original Submission: 4 January 2010; Revised Submission: 5 July 2010; Accepted: 23 July 2010 Editor: J.-M. Pawlotsky Article published online: 12 August 2010
References Clin Microbiol Infect 2011; 17: 949–951 1. Hubschen JM, Mbah PO, Forbi JC et al. Detection of a new subgenotype of Hepatitis B virus genotype A in Cameroon but not in neighbouring Nigeria. Clin Microbiol Infect 2010 (doi: 10.1111/j.1469-0691. 2010.03205.x). 2. Kurbanov F, Tanaka Y, Fujiwara K et al. A new subtype (subgenotype) Ac (A3) of hepatitis B virus and recombination between genotypes A and E in Cameroon. J Gen Virol 2005; 86: 2047–2056. 3. Pourkarim MR, Amini-Bavil-Olyaee S, Lemey P, Maes P, Van Ranst M. Are hepatitis B virus ‘‘subgenotypes’’ defined accurately? J Clin Virol 2010; 47: 356–360.
10.1111/j.1469-0691.2010.03342.x
Corresponding author: A. Dome´nech-Sa´nchez, Saniconsult Ibe´rica SL, Can Foradı´ 37, bajos. Son Cladera Nou., E 07009 Palma de Mallorca, Spain E-mail: [email protected]
ª2010 The Authors Clinical Microbiology and Infection ª2010 European Society of Clinical Microbiology and Infectious Diseases, CMI, 17, 947–954
950
Clinical Microbiology and Infection, Volume 17 Number 6, June 2011
Noroviruses represent an important cause of gastroenteritis outbreaks, in particular those related to closed or semiclosed communities such as hospitals, cruise ships and hotels [1–4]. A possible gastroenteritis outbreak in a hotel located in northern Majorca was reported on 23 June 2009. The subsequent investigation revealed a total of 14 cases with onset of symptoms from 18 June to 24 June. Norovirus was thought to be the pathogen responsible for the outbreak. A case was defined as any guest or employee of the hotel with acute onset of at least two of the following symptoms: diarrhoea, vomiting, abdominal clumps or fever (>37C). Cases were identified through the symptoms and epidemiological questionnaires provided by the medical staff attending the hotel. A total of 685 guests were resident in the hotel during the outbreak, and ten cases were identified among them: five adults (four women and one man), four children between 2 and 14 years old and one baby (<2 years old). The attack rates were 1.06%, 2.4% and 2.0%, respectively. Guests were attended by 90 employees, four of them (all women) being affected. In this case, the attack rate was 4.4%. However, when data only from the entertainment team were analysed, the attack rate increased to 66.7%, rising to 100% for those working directly in the children’s club of the hotel. The most frequent symptoms were vomiting (93%), diarrhoea (50%), abdominal pain (29%) and fever (7%). The duration of symptoms ranged from 1 to 4 days. Two children and one woman were hospitalized for hydration support, with good outcomes. Fig. 1 shows the evolution of cases, with an initial peak on 18 June and all the remaining cases between 21 June and 24 June. Initially, three members of the same family were affected, with one vomiting episode being described at the children’s club. A few days later, new cases appeared among guests and staff members. Both clinical and environmental samples were analysed to determine the aetiological agent of the outbreak. Four stool samples from four patients were taken for culture during the acute phase of the gastroenteritis. Samples were analysed for intestinal pathogens, including Salmonella, Shigella, Yersinia,
Number of cases
6
Adult guests
Child guests
Staff
5 4 3 2 1 0
16
17
18 19 20 21 22 23 24 Day of symptom onset, June 2009
25
26
FIG. 1. Evolution of cases, by date of onset of symptoms, for an outbreak of gastroenteritis in a hotel in Majorca, June 2009 (n = 14).
CMI
Cryptosporidium and norovirus. One sample from a child was also tested for rotavirus and adenovirus. Genotype 2 norovirus was detected in two of the four samples, one from an adult and one from a child, with the IDEIA Norovirus ELISA kit (DakoCytomation, Ely, UK). All other pathogens tested negative. Environmental samples were tested on 23 June. Food samples were analysed for total aerobic count, enterobacteria, Escherichia coli and other lactose-fermenting Enterobacteriaceae, Staphylococcus aureus, Salmonella and Listeria. Drinking water was tested for total aerobic count, E. coli and other coliforms, and Clostridium perfringens. Ice cubes were analysed for E. coli and other coliforms. Pool water samples were analysed for E. coli and other coliforms, S. aureus and Pseudomonas aeruginosa. Levels of microorganisms were acceptable in all cases, ruling out their role as a source of infection. As for the control procedures, once the gastroenteritis problem was spotted, a specially designed plan to solve the problem was rapidly implemented. Enhanced hand hygiene practices were established, and cleaning and disinfection of frequently contacted surfaces (doorknobs, phone keys, etc.) with 70% alcohol was performed. Common areas, especially toilets, were also frequently treated with bleach. Special care was taken in the children’s club and patients’ rooms. General guidelines included the following: the use of vapour for carpets and curtains and mopping for floor-cleaning instead of brooms and vacuum cleaners, to avoid air dissemination of norovirus; a long washing machine programme for virus inactivation in possibly contaminated clothes; and the use of masks, gloves and closed bags when dealing with vomit. Several cases of norovirus outbreaks have been described in hotels worldwide. However, to our knowledge, they have been described only in hospitals [5,6] and the community [7,8] in Spain. In Majorca, only one norovirus outbreak in a nursing home for the elderly has been reported [9]. In this article, we describe a gastroenteritis outbreak caused by norovirus in a hotel. Stool sample analysis demonstrated that genotype 2 norovirus, the most prevalent in recent years [10], was present in 50% of the tested samples, and no additional pathogen was detected. These results demonstrate that norovirus was the aetiological agent of the outbreak. Epidemiology data showed that all guest cases were children and members of their family, mainly their mothers. The affected staff were in direct contact with children, and some of the employees even worked at the children’s club. In fact, all of the employees belonging to this last group presented gastroenteritis symptoms. A vomiting episode was described at the beginning of the outbreak in the children’s club, and was probably the main source of infection.
ª2010 The Authors Clinical Microbiology and Infection ª2010 European Society of Clinical Microbiology and Infectious Diseases, CMI, 17, 947–954
Research Notes
CMI
Airborne and environmental transmission of norovirus after vomiting episodes is well established in hotel outbreaks [11–14]. The most probable scenario is that one member of the family affected by gastroenteritis symptoms on 18 June acquired the infection outside the hotel and infected members of their family through close contact, and that the rest of the patients became ill after acquiring norovirus at the children’s club, or indirectly from these people. Personto-person transmission is frequently associated with norovirus outbreaks [13,15]. In some cases, food and food-handlers or drinking water play a role in norovirus transmission [13,16–18]. Recreational water has also been involved in gastroenteritis outbreaks [19]. However, in our case, an origin within the hotel is improbable because: (i) analysis of environmental samples showed that food, drinking water and recreational water met the sanitary standards; and (ii) the number of cases would have been higher and more diverse. The characteristics of the affected people clearly indicate that the children’s club was directly or indirectly involved in all cases. In summary, the present investigation describes a gastroenteritis outbreak caused by norovirus, associated with a hotel children’s club. This case reflects the importance of a rapid analysis and response to control the outbreaks caused by norovirus in hotels, avoiding extreme measures such as closure because of the outbreak becoming out of control (Dome´nech-Sa´nchez A, 3rd Congress of European Microbiologists, FEMS, 2009, Abstract 3008).
Acknowledgements I thank the Leading Care and medical staff of the Red Asistencial Juaneda for their assistance and support. This study was partially presented on 12 April 2010 in the 20th ESCMID hosted in Vienna, Austria.
Transparency Declaration The author declares that no funding was received for this study and data were generated as part of routine activities. No conflicting or dual interests apply to the present article.
951
2. Centers for Disease Control and Prevention. Outbreaks of gastroenteritis associated with noroviruses on cruise ships—United States, 2002. MMWR 2002; 51: 1112–1115. 3. Medici MC, Morelli A, Arcangeletti MC et al. An outbreak of norovirus infection in an Italian residential-care facility for the elderly. Clin Microbiol Infect 2009; 15: 97–100. 4. Dome´nech-Sa´nchez A, Juan C, Rullan AJ, Perez JL, Berrocal CI. Gastroenteritis outbreaks in 2 tourist resorts, Dominican Republic. Emerg Infect Dis 2009; 15: 1877–1878. 5. Costas L, Vilella A, Llupia A, Bosch J, Jimenez de Anta MT, Trilla A. Outbreak of norovirus gastroenteritis among staff at a hospital in Barcelona, Spain, September 2007. Euro Surveill 2007; 12: E071122– E071125. 6. Godoy P, Dominguez A, Alvarez J et al. High incidence of outbreaks of norovirus GGII.4 in hospitals and nursing homes in Catalonia. J Hosp Infect 2009; 72: 275–277. 7. Sala MR, Arias C, Dominguez A, Bartolome R, Muntada JM. Foodborne outbreak of gastroenteritis due to Norovirus and Vibrio parahaemolyticus. Epidemiol Infect 2009; 137: 626–629. 8. Arias C, Sala MR, Domı´nguez A et al. Epidemiological and clinical features of norovirus gastroenteritis in outbreaks: a population-based study. Clin Microbiol Infect 2010; 16: 39–44. 9. Luque Ferna´ndez M, Galme´s Truyols A, Herrera Guibert D, Arbona Cerda´ G, Sancho Gaya´ F. Cohort study of an outbreak of viral gastroenteritis in a nursing home for elderly, Majorca, Spain, February 2008. Euro Surveill 2008; 13: pii-19070. 10. Buesa J, Collado B, Lopez-Andujar P et al. Molecular epidemiology of caliciviruses causing outbreaks and sporadic cases of acute gastroenteritis in Spain. J Clin Microbiol 2002; 40: 2854–2859. 11. Marks PJ, Vipond IB, Carlisle D, Deakin D, Fey RE, Caul EO. Evidence for airborne transmission of Norwalk-like virus (NLV) in a hotel restaurant. Epidemiol Infect 2000; 124: 481–487. 12. Cheesbrough JS, Green J, Gallimore CI, Wright PA, Brown DW. Widespread environmental contamination with Norwalk-like viruses (NLV) detected in a prolonged hotel outbreak of gastroenteritis. Epidemiol Infect 2000; 125: 93–98. 13. Love SS, Jiang X, Barrett E, Farkas T, Kelly S. A large hotel outbreak of Norwalk-like virus gastroenteritis among three groups of guests and hotel employees in Virginia. Epidemiol Infect 2002; 129: 127–132. 14. Kimura H, Nagano K, Kimura N et al. A norovirus outbreak associated with environmental contamination at a hotel. Epidemiol Infect 2010; 30: 1–9. 15. Michel A, Fitzgerald R, Whyte D et al. Norovirus outbreak associated with a hotel in the west of Ireland, 2006. Euro Surveill 2007; 12: E11–E12. 16. Dippold L, Lee R, Selman C, Monroe S, Henry C. A gastroenteritis outbreak due to norovirus associated with a Colorado hotel. J Environ Health 2003; 66: 13–17. 17. Sekla L, Stackiw W, Dzogan S, Sargeant D. Foodborne gastroenteritis due to Norwalk virus in a Winnipeg hotel. CMAJ 1989; 140: 1461– 1464. 18. Boccia D, Tozzi AE, Cotter B et al. Waterborne outbreak of Norwalk-like virus gastroenteritis at a tourist resort, Italy. Emerg Infect Dis 2002; 8: 563–568. 19. Dome´nech-Sa´nchez A, Olea F, Berrocal CI. Infections related to recreational waters [in Spanish]. Enferm Infecc Microbiol Clin 2008; 26 (suppl 4): 33–38
References 1. Parashar U, Quiroz ES, Mounts AW et al. ‘Norwalk-like viruses.’ Public health consequences and outbreak management. MMWR Recomm Rep 2001; 50 (RR-9): 1–17.
ª2010 The Authors Clinical Microbiology and Infection ª2010 European Society of Clinical Microbiology and Infectious Diseases, CMI, 17, 947–954
CMI
with the study of Hubschen et al. (Table 1). Tentative A7 strains showed less than 4% nucleotide divergence when compared with A1, and particularly with A3, A4 and A5. Similar results were obtained when tentative A7 was compared with quasi-subgenotype A3 (according to the recent proposed classification). We believe that a few selected strains as reference sequences are not representative of the nucleotide divergence because we obtained different results when analysing all available strains. Subgenotypes A1, A2 and A4 (previously known as A6) can be considered as definite ‘subgenotypes’, because they form clear phylogenetic clusters supported by high bootstrap values (Fig. 1), with considerable divergence in mean genetic distances. In conclusion, our analysis demonstrated that the introduced strains ‘tentative subgenotype A7’ did not meet the ‘subgenotype’ definition according to genetic distance and topology of phylogeny tree. Therefore, we propose that these strains should be also considered as new members of quasi-subgenotype A3. Moreover, their close evolutionary relationship with A3 is consistent with the geographical origins of the strains [2]. This finding highlights our hypothesis that geographical origin may have a key role in further classification of HBV subgenotypes [3]. In addition, it underscores the arguments of Schaefer et al. [4] on the roles of the International Committee on Taxonomy of Viruses (ICTV) as well as those of experts in HBV subgenotyping. Finally, we would like to stress again that the introduction of a new HBV genotype and especially a subgenotype should adhere to clear rules to avoid misclassification and confusion.
949
4. Schaefer S, Magnius L, Norder H. Under construction: classification of hepatitis B virus genotypes and subgenotypes. Intervirology 2009; 52: 323–325. 5. Kramvis A, Kew M, Francois G. Hepatitis B virus genotypes. Vaccine 2005; 23: 2409–2423. 6. Kramvis A, Arakawa K, Yu MC, Nogueira R, Stram DO, Kew MC. Relationship of serological subtype, basic core promoter and precore mutations to genotypes/subgenotypes of hepatitis B virus. J Med Virol 2008; 80: 27–46.
Gastroenteritis outbreak caused by norovirus associated with the children’s club of a hotel located in Majorca, Spain A. Dome´nech-Sa´nchez1,2 1) Saniconsult Ibe´rica SL, Palma de Mallorca and 2) A´rea de Microbiologı´a and Instituto Universitario de Investigacio´n en Ciencias de la Salud (IUNICS), Universidad de las Islas Baleares, Palma de Mallorca, Spain
Abstract A possible gastroenteritis outbreak in a hotel located in northern Majorca was reported on June 2009. The subsequent investigation revealed a total of 14 cases with onset of symptoms from 18 June to 26 June. Symptoms affected mainly the children, their parents and the staff related to the children’s club; a vomiting episode was described at the beginning of the outbreak. Genotype 2 norovirus was detected in stool samples, demonstrating its role as the aetiological agent. The special hygienic measures implemented allowed the outbreak to be controlled.
Transparency Declaration This study was co-funded by the institute for the Promotion of Innovation by Science and Technology in Flanders (strategic basic research project SIMID). All authors declare that they have no conflicts of interest.
Keywords: Children, gastroenteritis, hotel, norovirus, outbreak Original Submission: 4 January 2010; Revised Submission: 5 July 2010; Accepted: 23 July 2010 Editor: J.-M. Pawlotsky Article published online: 12 August 2010
References Clin Microbiol Infect 2011; 17: 949–951 1. Hubschen JM, Mbah PO, Forbi JC et al. Detection of a new subgenotype of Hepatitis B virus genotype A in Cameroon but not in neighbouring Nigeria. Clin Microbiol Infect 2010 (doi: 10.1111/j.1469-0691. 2010.03205.x). 2. Kurbanov F, Tanaka Y, Fujiwara K et al. A new subtype (subgenotype) Ac (A3) of hepatitis B virus and recombination between genotypes A and E in Cameroon. J Gen Virol 2005; 86: 2047–2056. 3. Pourkarim MR, Amini-Bavil-Olyaee S, Lemey P, Maes P, Van Ranst M. Are hepatitis B virus ‘‘subgenotypes’’ defined accurately? J Clin Virol 2010; 47: 356–360.
10.1111/j.1469-0691.2010.03342.x
Corresponding author: A. Dome´nech-Sa´nchez, Saniconsult Ibe´rica SL, Can Foradı´ 37, bajos. Son Cladera Nou., E 07009 Palma de Mallorca, Spain E-mail: [email protected]
ª2010 The Authors Clinical Microbiology and Infection ª2010 European Society of Clinical Microbiology and Infectious Diseases, CMI, 17, 947–954
950
Clinical Microbiology and Infection, Volume 17 Number 6, June 2011
Noroviruses represent an important cause of gastroenteritis outbreaks, in particular those related to closed or semiclosed communities such as hospitals, cruise ships and hotels [1–4]. A possible gastroenteritis outbreak in a hotel located in northern Majorca was reported on 23 June 2009. The subsequent investigation revealed a total of 14 cases with onset of symptoms from 18 June to 24 June. Norovirus was thought to be the pathogen responsible for the outbreak. A case was defined as any guest or employee of the hotel with acute onset of at least two of the following symptoms: diarrhoea, vomiting, abdominal clumps or fever (>37C). Cases were identified through the symptoms and epidemiological questionnaires provided by the medical staff attending the hotel. A total of 685 guests were resident in the hotel during the outbreak, and ten cases were identified among them: five adults (four women and one man), four children between 2 and 14 years old and one baby (<2 years old). The attack rates were 1.06%, 2.4% and 2.0%, respectively. Guests were attended by 90 employees, four of them (all women) being affected. In this case, the attack rate was 4.4%. However, when data only from the entertainment team were analysed, the attack rate increased to 66.7%, rising to 100% for those working directly in the children’s club of the hotel. The most frequent symptoms were vomiting (93%), diarrhoea (50%), abdominal pain (29%) and fever (7%). The duration of symptoms ranged from 1 to 4 days. Two children and one woman were hospitalized for hydration support, with good outcomes. Fig. 1 shows the evolution of cases, with an initial peak on 18 June and all the remaining cases between 21 June and 24 June. Initially, three members of the same family were affected, with one vomiting episode being described at the children’s club. A few days later, new cases appeared among guests and staff members. Both clinical and environmental samples were analysed to determine the aetiological agent of the outbreak. Four stool samples from four patients were taken for culture during the acute phase of the gastroenteritis. Samples were analysed for intestinal pathogens, including Salmonella, Shigella, Yersinia,
Number of cases
6
Adult guests
Child guests
Staff
5 4 3 2 1 0
16
17
18 19 20 21 22 23 24 Day of symptom onset, June 2009
25
26
FIG. 1. Evolution of cases, by date of onset of symptoms, for an outbreak of gastroenteritis in a hotel in Majorca, June 2009 (n = 14).
CMI
Cryptosporidium and norovirus. One sample from a child was also tested for rotavirus and adenovirus. Genotype 2 norovirus was detected in two of the four samples, one from an adult and one from a child, with the IDEIA Norovirus ELISA kit (DakoCytomation, Ely, UK). All other pathogens tested negative. Environmental samples were tested on 23 June. Food samples were analysed for total aerobic count, enterobacteria, Escherichia coli and other lactose-fermenting Enterobacteriaceae, Staphylococcus aureus, Salmonella and Listeria. Drinking water was tested for total aerobic count, E. coli and other coliforms, and Clostridium perfringens. Ice cubes were analysed for E. coli and other coliforms. Pool water samples were analysed for E. coli and other coliforms, S. aureus and Pseudomonas aeruginosa. Levels of microorganisms were acceptable in all cases, ruling out their role as a source of infection. As for the control procedures, once the gastroenteritis problem was spotted, a specially designed plan to solve the problem was rapidly implemented. Enhanced hand hygiene practices were established, and cleaning and disinfection of frequently contacted surfaces (doorknobs, phone keys, etc.) with 70% alcohol was performed. Common areas, especially toilets, were also frequently treated with bleach. Special care was taken in the children’s club and patients’ rooms. General guidelines included the following: the use of vapour for carpets and curtains and mopping for floor-cleaning instead of brooms and vacuum cleaners, to avoid air dissemination of norovirus; a long washing machine programme for virus inactivation in possibly contaminated clothes; and the use of masks, gloves and closed bags when dealing with vomit. Several cases of norovirus outbreaks have been described in hotels worldwide. However, to our knowledge, they have been described only in hospitals [5,6] and the community [7,8] in Spain. In Majorca, only one norovirus outbreak in a nursing home for the elderly has been reported [9]. In this article, we describe a gastroenteritis outbreak caused by norovirus in a hotel. Stool sample analysis demonstrated that genotype 2 norovirus, the most prevalent in recent years [10], was present in 50% of the tested samples, and no additional pathogen was detected. These results demonstrate that norovirus was the aetiological agent of the outbreak. Epidemiology data showed that all guest cases were children and members of their family, mainly their mothers. The affected staff were in direct contact with children, and some of the employees even worked at the children’s club. In fact, all of the employees belonging to this last group presented gastroenteritis symptoms. A vomiting episode was described at the beginning of the outbreak in the children’s club, and was probably the main source of infection.
ª2010 The Authors Clinical Microbiology and Infection ª2010 European Society of Clinical Microbiology and Infectious Diseases, CMI, 17, 947–954
Research Notes
CMI
Airborne and environmental transmission of norovirus after vomiting episodes is well established in hotel outbreaks [11–14]. The most probable scenario is that one member of the family affected by gastroenteritis symptoms on 18 June acquired the infection outside the hotel and infected members of their family through close contact, and that the rest of the patients became ill after acquiring norovirus at the children’s club, or indirectly from these people. Personto-person transmission is frequently associated with norovirus outbreaks [13,15]. In some cases, food and food-handlers or drinking water play a role in norovirus transmission [13,16–18]. Recreational water has also been involved in gastroenteritis outbreaks [19]. However, in our case, an origin within the hotel is improbable because: (i) analysis of environmental samples showed that food, drinking water and recreational water met the sanitary standards; and (ii) the number of cases would have been higher and more diverse. The characteristics of the affected people clearly indicate that the children’s club was directly or indirectly involved in all cases. In summary, the present investigation describes a gastroenteritis outbreak caused by norovirus, associated with a hotel children’s club. This case reflects the importance of a rapid analysis and response to control the outbreaks caused by norovirus in hotels, avoiding extreme measures such as closure because of the outbreak becoming out of control (Dome´nech-Sa´nchez A, 3rd Congress of European Microbiologists, FEMS, 2009, Abstract 3008).
Acknowledgements I thank the Leading Care and medical staff of the Red Asistencial Juaneda for their assistance and support. This study was partially presented on 12 April 2010 in the 20th ESCMID hosted in Vienna, Austria.
Transparency Declaration The author declares that no funding was received for this study and data were generated as part of routine activities. No conflicting or dual interests apply to the present article.
951
2. Centers for Disease Control and Prevention. Outbreaks of gastroenteritis associated with noroviruses on cruise ships—United States, 2002. MMWR 2002; 51: 1112–1115. 3. Medici MC, Morelli A, Arcangeletti MC et al. An outbreak of norovirus infection in an Italian residential-care facility for the elderly. Clin Microbiol Infect 2009; 15: 97–100. 4. Dome´nech-Sa´nchez A, Juan C, Rullan AJ, Perez JL, Berrocal CI. Gastroenteritis outbreaks in 2 tourist resorts, Dominican Republic. Emerg Infect Dis 2009; 15: 1877–1878. 5. Costas L, Vilella A, Llupia A, Bosch J, Jimenez de Anta MT, Trilla A. Outbreak of norovirus gastroenteritis among staff at a hospital in Barcelona, Spain, September 2007. Euro Surveill 2007; 12: E071122– E071125. 6. Godoy P, Dominguez A, Alvarez J et al. High incidence of outbreaks of norovirus GGII.4 in hospitals and nursing homes in Catalonia. J Hosp Infect 2009; 72: 275–277. 7. Sala MR, Arias C, Dominguez A, Bartolome R, Muntada JM. Foodborne outbreak of gastroenteritis due to Norovirus and Vibrio parahaemolyticus. Epidemiol Infect 2009; 137: 626–629. 8. Arias C, Sala MR, Domı´nguez A et al. Epidemiological and clinical features of norovirus gastroenteritis in outbreaks: a population-based study. Clin Microbiol Infect 2010; 16: 39–44. 9. Luque Ferna´ndez M, Galme´s Truyols A, Herrera Guibert D, Arbona Cerda´ G, Sancho Gaya´ F. Cohort study of an outbreak of viral gastroenteritis in a nursing home for elderly, Majorca, Spain, February 2008. Euro Surveill 2008; 13: pii-19070. 10. Buesa J, Collado B, Lopez-Andujar P et al. Molecular epidemiology of caliciviruses causing outbreaks and sporadic cases of acute gastroenteritis in Spain. J Clin Microbiol 2002; 40: 2854–2859. 11. Marks PJ, Vipond IB, Carlisle D, Deakin D, Fey RE, Caul EO. Evidence for airborne transmission of Norwalk-like virus (NLV) in a hotel restaurant. Epidemiol Infect 2000; 124: 481–487. 12. Cheesbrough JS, Green J, Gallimore CI, Wright PA, Brown DW. Widespread environmental contamination with Norwalk-like viruses (NLV) detected in a prolonged hotel outbreak of gastroenteritis. Epidemiol Infect 2000; 125: 93–98. 13. Love SS, Jiang X, Barrett E, Farkas T, Kelly S. A large hotel outbreak of Norwalk-like virus gastroenteritis among three groups of guests and hotel employees in Virginia. Epidemiol Infect 2002; 129: 127–132. 14. Kimura H, Nagano K, Kimura N et al. A norovirus outbreak associated with environmental contamination at a hotel. Epidemiol Infect 2010; 30: 1–9. 15. Michel A, Fitzgerald R, Whyte D et al. Norovirus outbreak associated with a hotel in the west of Ireland, 2006. Euro Surveill 2007; 12: E11–E12. 16. Dippold L, Lee R, Selman C, Monroe S, Henry C. A gastroenteritis outbreak due to norovirus associated with a Colorado hotel. J Environ Health 2003; 66: 13–17. 17. Sekla L, Stackiw W, Dzogan S, Sargeant D. Foodborne gastroenteritis due to Norwalk virus in a Winnipeg hotel. CMAJ 1989; 140: 1461– 1464. 18. Boccia D, Tozzi AE, Cotter B et al. Waterborne outbreak of Norwalk-like virus gastroenteritis at a tourist resort, Italy. Emerg Infect Dis 2002; 8: 563–568. 19. Dome´nech-Sa´nchez A, Olea F, Berrocal CI. Infections related to recreational waters [in Spanish]. Enferm Infecc Microbiol Clin 2008; 26 (suppl 4): 33–38
References 1. Parashar U, Quiroz ES, Mounts AW et al. ‘Norwalk-like viruses.’ Public health consequences and outbreak management. MMWR Recomm Rep 2001; 50 (RR-9): 1–17.
ª2010 The Authors Clinical Microbiology and Infection ª2010 European Society of Clinical Microbiology and Infectious Diseases, CMI, 17, 947–954