The Centers for Disease Control and Prevention (CDC) estimates that noroviruses cause 23 million cases of acute gastroenteritis annually, making noroviruses the leading cause of gastroenteritis in the United States (CDC, 2006; Fankhauser, et al., 2002; Mead, et al., 1999).
Of viruses, only the common cold is reported more often than viral gastroenteritis (norovirus) (Benson & Merano, 1998).
Nature has created an ingenious bug in norovirus. The round blue ball structure of norovirus is actually a protein surrounding the virus’s genetic material. The virus attaches to the outside of cells lining the intestine, and then transfers its genetic material into those cells. Once the genetic material has been transferred, norovirus reproduces, finally killing the human cells and releasing new copies of itself that attach to more cells of the intestine’s lining.
Norovirus (previously called “Norwalk-like virus” or NLV) is a member of the family Caliciviridae. The name derives from the Latin for chilice—calyx—meaning cup-like, and refers to the indentations of the virus surface.
The family of Caliciviridae consists of several distinct groups of viruses that were first named after the places where outbreaks occurred. The first such outbreak occurred in 1968 among schoolchildren in Norwalk, Ohio (Glass, et al., 2000). The prototype strain was identified four years later, in 1972, and was the first virus identified that specifically caused gastroenteritis in humans (Glass, et al., 2000).
Other discoveries followed, with each strain name based on the location of its discovery-location, e.g., Montgomery County, Snow Mountain, Mexico, Hawaii, Parmatta, Taunton, and Toronto viruses. A study published in 1977 found that the Toronto virus was the second most common cause of gastroenteritis in children (Middleton, Szmanski & Petric, 1977).
Eventually this confusing nomenclature was rsolved, first in favor of calling each of the strains a Norwalk-like virus, and then simply, a norovirus – the term used today.
How is norovirus transmitted?
Noroviruses are transmitted primarily through the fecal-oral route, and fewer than 100 norovirus particles are said to be needed to cause infection (MMWR, 2001, June 1).
Transmission occurs either person-to-person or through contamination of food or water. Foodborne norovirus transmission can occur when food is contaminated by an infected food handler (Caceres, et al., 1998; MMWR, 2001, June 1).
Noroviruses are recognized as causing over half of all foodborne illness outbreaks. CDC statistics show that food is the most common vehicle of transmission for noroviruses; of 232 outbreaks of norovirus between July 1997 and June 2000, 57% were foodborne, 16% were spread from person-to-person, and 3% were waterborne (CDC, 2006, August 3).
The virus is shed in large numbers in the vomit and stool of infected individuals, most commonly while they are ill. Some individuals may, however, continue to shed norovirus long after they have recovered from the illness (Patterson, 1993). Aerosolized vomit has also been implicated as a mode of norovirus transmission (Marks, et al., 2000).
As noted by the CDC in its Final Trip Report, “noroviruses can cause extended outbreaks because of their high infectivity, persistence in the environment, resistance to common disinfectants, and difficulty in controlling their transmission through routine sanitary measures” (MMWR, 2001, June 1).
Diagnosis is often based on the combination of symptoms, particularly the prominence of vomiting, little fever, and the short duration of illness. If a known norovirus outbreak is in progress, public health officials may obtain specimens from ill individuals for testing in a lab.
Norovirus can be identified in a lab under an electron microscope. A reverse transcriptase polymerase chain reaction test (RT-PCR assay) also can detect norovirus in food, water, stool samples, and on surfaces. These tests isolate and replicate the suspected virus’ genetic material for analysis (Mayo Clinic, 2007).
Treatment for Norovirus Infection
No specific treatment is available for norovirus. In most healthy people, the illness usually is self-limiting and resolves in a few days.
Outbreaks among infants, children, elderly, and immunocompromised populations may result in severe complications among those affected. Death may result without prompt measures (Mayo Clinic, 2007, April 5).
The replacement of fluids and minerals such as sodium, potassium and calcium – otherwise known as electrolytes – lost due to persistent diarrhea is vital. This can be done either by drinking large amounts of liquids, or intravenously (Mayo Clinic, 2007, April 5).
Preventing Norovirus Infection
Common settings for norovirus outbreaks include restaurants and events with catered meals (36%), nursing homes (23%), schools (13%), and vacation settings or cruise ships (10%) (CDC, 2006, August 3). Proper hand washing is the best way to prevent the spread of norovirus.
The good news about norovirus is that it does not multiply in foods as many bacteria do. In addition, thorough cooking destroys this virus. To avoid norovirus, make sure the food you eat is cooked completely.
Shellfish (oysters, clams, mussels) pose the greatest risk and any particular serving may be contaminated with norovirus; there is no way to detect a contaminated oyster, clam, or mussel from a safe one. Shellfish become contaminated when their waters become contaminated (e.g. when raw sewage is dumped overboard by recreational and/or commercial boaters). Shellfish are filter feeders and will concentrate virus particles present in their environment. With shellfish, only complete cooking offers reliable protection; steaming does not kill the virus or prevent its transmission (Kirkland, et al., 1996).
Raw vegetables should be washed thoroughly before being served, and travelers should drink only boiled drinks or carbonated bottled beverages without ice when in areas that have polluted water sources.
Immunity to calciviruses is not permanent and re-infection can occur. Infection may also spread from person-to-person. So, if you or another household member suffer a bout of gastroenteritis, be absolutely sure to wash hands with soap and warm water after toilet visits, before preparing or eating food, and after caring for the sick. Exclude persons with gastroenteritis from the kitchen, and always dispose of sewage in a sanitary manner.
Recently, outbreaks of norovirus have become synonymous with cruise ships (CDC, 2006, August 3; MMWR Weekly, 2002, December 13). Healthcare facilities also experience a high incidence of norovirus outbreaks. The CDC has published information regarding the prevention of norovirus outbreaks on cruise ships and in healthcare facilities on its website (CDC, 2006, December 21; CDC, 2007).
* Bravo! Cucina Italiano Norovirus Outbreak
* Campylobacter Outbreak – Washington State Penitentiary
* Carrabba’s Restaurant Norovirus Outbreak
* Las Vegas Flamingo Norovirus Outbreak
* Michigan Blimpie’s Norovirus Outbreak
* Regent Beverly Wilshire Hotel Norovirus Outbreak
* Si Casa Flores Norovirus Outbreak
- Benson V, Merano MA. (1998). Current estimates from the National Health Interview Survey 1995. National Center for Health Statistics. Vital Health Stat 10. 1998;(199).
- Cáceres VM, Kim DK, Bresee JS, Horan J, Noel JS, Ando T, Steed CJ, Weems JJ, Monroe SS, and Gibson JJ. (1998). A viral gastroenteritis outbreak associated with person-to-person spread among hospital staff. Infect Control Hosp Epidemiol. 19(3):162-7.
- CDC. (2006, August 3). Norovirus: Technical Fact Sheet. Retrieved August 14, 2007 from Centers for Disease Control and Prevention Web site, http://www.cdc.gov/ncidod/dvrd/revb/gastro/norovirus-factsheet.htm.
- CDC. (2006, December 21). Norovirus in Healthcare Facilities Fact Sheet. Retrieved August 15, 2007 from Centers for Disease Control and Prevention Web site, http://www.cdc.gov/ncidod/dhqp/id_norovirusFS.html.
- CDC. 2007. Facts about Norovirus on Cruise Ships. Retrieved August 15, 2007 from Centers for Disease Control and Prevention Web site, http://www.cdc.gov/nceh/vsp/pub/Norovirus/Norovirus.htm.
- Fankhauser RL, Monroe SS, Noel JS, Humphrey CD, Bresee JS, Parashar UD, Ando T, and Glass RI. (2002). Epidemiologic and molecular trends of ‘Norwalk-like viruses’ associated with outbreaks of gastroenteritis in the United States. J. Infect. Dis. 186(1):1-7.
- Glass RI, Noel J, Ando T, Fankhauser R, Belliot G, Mounts A, Parashar UD, Bresee JS, and Monroe SS. (2000). The Epidemiology of Enteric Calciviruses from Humans: A Reassessment Using New Diagnostics. J. Infect. Dis. 181(Suppl 2):S254-61.
- Kirkland KB, Meriwether RA, Leiss JK, and MacKenzie WR. (1996). Steaming oysters does not prevent Norwalk-like gastroenteritis. Public Health Rep. 111:527-30.
- Marks PJ, Vipond IB, Carlisle D, Deakin D, Fey RE, and Caul EO. (2000). Evidence of airborne transmission of Norwalk-like virus (NLV) in a hotel restaurant. Epidemiol. Infect. 124(3):481-87
- Mayo Clinic. (2007, April 5). Norovirus. Retrieved August 15, 2007 from Mayo Clinic Web site: http://www.mayoclinic.com/health/norovirus/DS00942/DSECTION=1.
- Mead PS, Slutsker L, Dietz V, McCaig LF, Bresee JS, Shapiro C, Griffin PM, and Tauxe Rv. (1999). Food-related illness and death in the United States. Emerg Infect Dis 5:607-25.
- Middleton PJ, Szmanski MT, and Petric M. (1977). Viruses associated with acute gastroenteritis in young children. Am J Dis Child. 131:733.
- MMWR Weekly. (2002). Outbreaks of Gastroenteritis Associated with Noroviruses on Cruise Ships – United States, 2002. December 13, 2002 / 51(49);1112-1115. Atlanta, GA: Centers for Disease Control and Prevention.
- MMWR Weekly. (2001). ‘Norwalk-like viruses’—Public health consequences and outbreak management. June 1, 2001 / 50:1-18. Atlanta, GA: Centers for Disease Control and Prevention.
- Patterson T, Hutchin P, and Palmer S. (1993). Outbreak of SRSV gastroenteritis at an international conference traced to food handled by a post symptomatic caterer. Epidemiol Infect. 111:157-162.