Agents of Viral Gastroenteritis
Erik Reisdorf CLS M (NCA)Advanced MicrobiologistCommunicable Disease DivisionWisconsin State Laboratory of HygieneFebruary 25, 2004
ACUTE INFECTIOUS GASTROENTERITISPUBLIC HEALTH IMPACT United StatesSecond most common clinical entityGreatest clinical impact on children < 5500,000 physician visits55,000 children hospitalized per year>500 deaths per year$1 billion in total costsWorldwide Estimated 3-5 billion cases occur annually5-10 million deaths annually primarily in developing countries
Incidence of Foodborne Illness
Incidence of cases of infection with pathogens under surveillance by CDC (FoodNET)
United States 2001
Pathogen (bacterial/parasitic)
Overall Incidence (per 100,000)
Salmonella
15.1
Campylobacter
13.8
Shigella
6.4
E. coli 0157
1.6
Cryptosporidium
1.5
HUS
0.9
Yersinia
0.4
Listeria
0.3
Vibrio
0.2
Cyclospora
0.1
Etiologic Agents Associated With FBOs 1991-2000 (n=231)
FOODBORNE & WATERBORNE GASTROENTERITISAn Emerging Public Health Problem
FOODBORNE & WATERBORNE GASTROENTERITISThe Viral AgentsNorovirus (norwalk-like)Rotavirus Adenovirus 40/41 AstrovirusOther?
FOODBORNE & WATERBORNE GASTROENTERITIS CLUES AS TO ETIOLOGYClinical FeaturesIncubation PeriodDuration of IllnessSeasonalityGeographic Location
FOODBORNE & WATERBORNE GASTROENTERITISClinical Clues
FOODBORNE & WATERBORNE GASTROENTERITIS CLINICAL CLUES (V)Nausea, Vomiting, and Diarrhea Incubation:24 - 48 hoursDuration:24 - 48 hours
Etiology:norovirus (previously known as norwalk-like virus)
FOODBORNE & WATERBORNE GASTROENTERITIS NOROVIRUS
FOODBORNE & WATERBORNE GASTROENTERITISHelpful Hints for the Clueless ClinicianBloody (with mucus) diarrheaFeverChronicityAgeSeasonalityTwo or more people involvedRetrospective chart reviewWhen in doubt, contact your LPHA
VIRAL GASTROENTERITISMajor Etiologic AgentsNorovirus Largest cause of outbreaks of nonbacterial gastroenteritis (>90%)RotavirusesAdenovirus Types 40 and 41Astroviruses
OTHER VIRUSES IMPLICATED IN GASTROENTERITISSRSVscoronavirusPestivirusPicobirnavirusTorovirus Parvovirus Etiological role and public health significance unclear!
VIRAL GASTROENTERITISEnteroviruses Another Major Player?
NOT!
VIRAL GASTROENTERITISRotavirusesFamily ReoviridaedsRNA (11 segments), non-enveloped; 70nm5 groups, A - E:Group A (subtypes 1 - 4) - 1 human pathogensGroup B - extensive outbreaks in ChinaGroup C - occasional illness worldwideGroups D and E - animal pathogens
VIRAL GASTROENTERITISRotavirus Clinical IllnessIncubation period: 1 - 3 daysDuration: 3 - 8 daysCharacteristic clinical triad:fevervomitingdiarrheaFrequent coryza and coughDehydration is leading complication
VIRAL GASTROENTERITISRotavirus EpidemiologyMax. incidence of illness: 6 - 24 monthsReinfection common throughout lifeInfections at < 6 months and > 5 years of age often asymptomatic or mildSeasonality: Marked; winter-spring peak in WITransmission:person-to-person; fecal - oral; respiratory?
ROTAVIRUS IN WISCONSIN
Chart1
1195.2631578947
42913.7931034483
1234.347826087
0300
0320
21910.5263157895
1175.8823529412
21811.1111111111
21910.5263157895
1520
32512
1185.5555555556
2229.0909090909
2355.7142857143
43810.5263157895
53514.2857142857
3339.0909090909
53613.8888888889
114425
3446.8181818182
125024
95715.7894736842
85016
155626.7857142857
206132.7868852459
338339.7590361446
268231.7073170732
398844.3181818182
326946.3768115942
4010040
4610444.2307692308
479648.9583333333
489948.4848484848
6112449.1935483871
398744.8275862069
479251.0869565217
388544.7058823529
259626.0416666667
165529.0909090909
73321.2121212121
166126.2295081967
3407.5
3456.6666666667
33010
Data Collated by WSLH
Pos. Rota
Total Rota
% Pos. Rota
Week Ending
No. Pos/Tested
Percent Pos.
ro9596
BellinSt. VincentsGundersen LutheranSt. MarysWSLHMarshfieldMilwaukee HlthUnited RegionalChildrensMedical ScienceTotal
PosTotalPosTotalPosTotalPosTotalPosTotalPosTotalPosTotalPosTotalPosTotalPosTotalPos
11/25/9500
12/2/95110
12/9/95110
12/16/9500
12/23/9500
12/30/95110
1/6/9600
1/13/9600
1/20/96220
1/27/9611350
2/3/9600
2/10/96330
2/17/962350
2/24/96417354240
3/2/96433363220
3/9/9613117130
3/16/96422254190
3/23/9668251174430
3/30/96487723113378
4/6/9634833102330
4/13/96534312270
4/20/96342371200
4/27/964311180
5/4/962431100
5/11/963140
5/18/9631260
5/25/9611130
6/1/96220
6/8/9600
6/15/96110
6/22/9600200020006028
6/29/9600100130016039
2584105602602601055250001120030525
&CNumber of Patients Tested and Positive for Rotavirus in Wisconsin
ro9596
0000000000
0000000000
0000000000
0000000000
0000000000
0000000000
0000000000
0000000000
0000000000
0000000000
0000000000
0000000000
0000000000
0000000000
0000000000
0000000000
0000000000
0000000000
0000000000
0000000000
0000000000
0000000000
0000000000
0000000000
0000000000
0000000000
0000000000
0000000000
0000000000
0000000000
0000000000
0000000000
&CNumber of Patients Tested and Positive for Rotavirus in Wisconsin
Bellin Pos
Bellin Total
St. Vincents Pos
St. Vincents Total
Gundersen Lutheran Pos
Gundersen Lutheran Total
St. Marys Pos
St. Marys Total
WSLH Pos
WSLH Total
Marshfield Pos
Marshfield Total
Milwaukee Hlth Pos
Milwaukee Hlth Total
United Regional Pos
United Regional Total
Childrens Pos
Childrens Total
Medical Science Pos
ro9697
BellinSt. VincentsGundersen LutheranSt. MarysWSLHMarshfieldMilwaukee HlthUnited RegionalChildrensMedical ScienceTotalTotalPercent
PosTotalPosTotalPosTotalPosTotalPosTotalPosTotalPosTotalPosTotalPosTotalPosTotalPos. RotaTotal Rota% Pos. Rota
7/6/9616000108031185.56
7/13/96020100150011021811.11
7/20/96110005010001051137.69
7/27/9601000002040017001147.14
8/3/96000000020102030006000140.00
8/10/960911010003020002001185.56
8/17/960101010006030006000180.00
8/24/960401020003060101030210.00
8/31/960201010105120006021205.00
9/7/960302110101010305021195.26
9/14/961202030039060200030242913.79
9/21/96020100001407040005001234.35
9/28/960800020102020300011010300.00
10/5/960702030102010200012020320.00
10/12/9605000011031301050121910.53
10/19/961400000405000004001175.88
10/26/9611050300150300010021811.11
11/2/961213020000060300020121910.53
11/9/960200110000020000001520.00
11/16/963701000202040200060132512.00
11/23/960306000001010401121185.56
11/30/96020200010202030029012229.09
12/7/960206010101010501216012355.71
12/14/9613030202010405023140243810.53
12/21/9600000101010502015220253514.29
12/28/960211030001020402218003339.09
1/4/9704020200000105025190153613.89
1/11/97361412001113040141904114425.00
1/18/970501030105061300217033446.82
1/25/97010212011213170282901125024.00
2/1/9702130503010714047240495715.79
2/8/97150203001207111004161485016.00
2/15/971337022313210170141911155626.79
2/22/9701381115021331200102613206132.79
3/1/97137130245234173600113212338339.76
3/8/9727816250035082120292601268231.71
3/15/971856032301374800245101398844.32
3/22/974658222302280401163411326946.38
3/29/973861211226841507021640254010040.00
4/5/9751461222122341025112252134610444.23
4/12/97610493411454112511214515479648.96
4/19/97698127712239192711113514489948.48
4/26/977101115577141861526121842356112449.19
5/3/9757694503376183912112601398744.83
5/10/977108123557241021260162046479251.09
5/17/97474823442511201100082523388544.71
5/24/97510292627136200150062511259626.04
5/31/9725292501491200524165529.09
6/7/9737030301132400001120073321.21
6/14/9731138230113510030321900166126.23
6/21/9714240000040100300014013407.50
6/28/972500130007050904010023456.67
7/5/970700220101050700061133010.00
7/12/97070104000019050005021333.03
7/19/970201000309090001000250.00
7/26/970105000103040008020240.00
8/2/97020801014040405050430.00
8/9/9703000105090008020280.00
00
8025898252471243486391538839634269542248911211006942591
31.0138.8937.9039.5325.4922.2212.6411.9027.2221.0026.79
&CNumber of Patients Tested and Positive for Rotavirus in Wisconsin
&C&P
ro9697
35252352521600352523525201083525235252352523525233525235252118
3525935259020135259352590015352593525900103525935259218
3526635266352663526611000501352663526600105113
35273352730100000204352733527300700114
0000000201020300600014
093528735287110100030200200118
013529435294010100060300600018
043530135301010200030601103021
023530835308010101051200602120
030211010101353153531503502119
1202030039060200302429
0201000014070400500123
08000201020203001101030
07020301020102001202032
053535035350000011031301501219
143535735357000004050000400117
110503353643536400150300100218
1213020000060300201219
0200110000020000353780015
3701000202040200601325
030600000101040123539235392118
0202000102020300901222
02060101010105011601235
13030202010405021402438
00000101010502012202535
02110300010204021800333
04020200000105021901536
361412001113040119041144
05010301050613001703344
010212011213170229011250
02130503010714042404957
150203001207111001614850
1337022313210170119111556
0138111502133120026132061
13713024523417360032123383
27816250035082120226012682
185603230137480051013988
465822230228040134113269
386121122684150702402540100
5146122212234102511521346104
61049341145411251145154796
69812771223919271135144899
710111557714186152612423561124
5769450337618391226013987
7108123557241021260120464792
474823442511201100025233885
510292627136200150025112596
&CNumber of Patientse Tested and Positive for Rotavirus in Wisconsin
Bellin Pos
Bellin Total
St. Vincents Pos
St. Vincents Total
Gundersen Lutheran Pos
Gundersen Lutheran Total
St. Marys Pos
St. Marys Total
WSLH Pos
WSLH Total
Marshfield Pos
Marshfield Total
Milwaukee Hlth Pos
Milwaukee Hlth Total
United Regional Pos
United Regional Total
Childrens Total
Medical Science Pos
Medical Science Total
Total Pos
Total Tested
rota 9697
&C&"Arial,Bold"&14Number of Patients Tested and Positive for Rotavirus&12Week Ending September 6, 1997 - April 25, 1998
rota 9697
1195.2631578947
42913.7931034483
1234.347826087
0300
0320
21910.5263157895
1175.8823529412
21811.1111111111
21910.5263157895
1520
32512
1185.5555555556
2229.0909090909
2355.7142857143
43810.5263157895
53514.2857142857
3339.0909090909
53613.8888888889
114425
3446.8181818182
125024
95715.7894736842
85016
155626.7857142857
206132.7868852459
338339.7590361446
268231.7073170732
398844.3181818182
326946.3768115942
4010040
4610444.2307692308
479648.9583333333
489948.4848484848
6112449.1935483871
398744.8275862069
479251.0869565217
388544.7058823529
259626.0416666667
165529.0909090909
73321.2121212121
166126.2295081967
3407.5
3456.6666666667
33010
Data Collated by WSLH
Pos. Rota
Total Rota
% Pos. Rota
Week Ending
No. Pos/Tested
Percent Pos.
rocurve
rocurve
35252103525200352523525203525218
3525900352590135259013525918
352663526610003526600013
35273000003527301014
000000000014
0352871000000018
0352940000000018
0353010000000021
0353080000100020
0010003531500019
100030000029
000010000023
000000000030
000000000032
0353500010100019
1353570000000017
1003536401000018
110000000019
001000003537805
300000000025
0000000013539218
000000002022
000000002035
100000003038
000000005035
010000002033
000000005036
311011004044
000000102044
001011108050
010000107057
100010104150
130212104156
0311013010161
1704243011183
282030209082
1502034024088
4522020016169
36126400162100
56212421221104
6431442121196
6871292111199
711571621183124
5640363111087
7835210206492
4424211108285
522216006196
22235581041053558155
300012001033
332015002061
120000000040
201000000045
002000000130
000001000033
0003563000000025
0003563700000024
00035644000356440043
35651356510000000028
0
&C&"Arial,Bold"&14Number of Patients Tested and Positive for Rotavirus in Wisconsin
Bellin Pos
St. Vincents Pos
Gundersen Lutheran Pos
St. Marys Pos
WSLH Pos
Marshfield Pos
Milwaukee Hlth Pos
United Regional Pos
Childrens Pos
Medical Science Pos
Total Tested
Week Ending
No. Positive
No. Tested
rocurve no tot
rocurve no tot
00100035315000
1000300000
0000100000
0000000000
0000000000
03535000101000
13535700000000
10035364010000
1100000000
00100000353780
3000000000
00000000135392
0000000020
0000000020
1000000030
0000000050
0100000020
0000000050
3110110040
0000001020
0010111080
0100001070
1000101041
1302121041
03110130101
17042430111
2820302090
15020340240
45220200161
36126400162
56212421221
64314421211
68712921111
711571621183
56403631110
78352102064
44242111082
5222160061
&C&"Arial,Bold"&14Number of Patients Tested and Positive for Rotavirus in Wisconsin
Bellin Pos
St. Vincents Pos
Gundersen Lutheran Pos
St. Marys Pos
WSLH Pos
Marshfield Pos
Milwaukee Hlth Pos
United Regional Pos
Childrens Pos
Medical Science Pos
Week Ending
No. Positive
Rota 9798
Rota 9798
0240
0330
0250
1234.347826087
2248.3333333333
1185.5555555556
0220
0210
1214.7619047619
0200
21513.3333333333
2296.8965517241
1244.1666666667
32015
3417.3170731707
4626.4516129032
0460
4478.5106382979
75313.2075471698
115918.6440677966
95217.3076923077
4527.6923076923
4577.0175438596
74316.2790697674
106116.393442623
105717.5438596491
208025
2610325.2427184466
358541.1764705882
328836.3636363636
388246.3414634146
429345.1612903226
409243.4782608696
256637.8787878788
Data Collated by WSLH
Rota
Total Rota
% Pos Rota
Week Ending
No. Pos./Tested
Percent Pos.
Number of Patients Tested and Positive for RotavirusWeek Ending September 6, 1997 - April 25, 1998
VIRAL GASTROENTERITISCalicivirusesFamily Caliciviridaegenus norovirusssRNA, non-enveloped; 26 - 34 nm4 genogroups; GI 25% GII 75% GIII+IV animalsMany different genetic clusters (>17)
VIRAL GASTROENTERITISNorovirus Clinical IllnessIncubation: 1-2 daysDuration: 2-3 daysAbrupt onset of nausea and vomiting with prostration and malaiseNausea, vomiting, diarrhea, and headache >50%
VIRAL GASTROENTERITISNorovirus Epidemiology23 million annuallyAll ages affected Occurs year aroundWinter vomiting diseaseExplosive family, institutional, and community-wide outbreaksasymptomatic excretion
VIRAL GASTROENTERITISNorovirus CharacteristicsNon cultivitableVomitus infectiousReservoirHighly transmissible Environmentally stable
Seasonality
Person-to-Person Spread
Wisconsin: winter of 2002-2003
WisconsinNovember 2002 through February 2003 there was a marked increase outbreaks:9 institutional2000: 22001: 4
The National PictureTrend reflected nationally:Washington State:November- December 2002: 10 outbreaks (6 LTCF)New Hampshire:November-December 2002: 29 outbreaks (LTCF)NYC:November-January 2003: 66 outbreaks of AGE (51 LTCF)
Theories???
VIRAL GASTROENTERITISAdenovirusesFamily AdenoviridaedsDNA, non-enveloped; 70 - 75 nm2 enteric serotypes: 40 and 41
VIRAL GASTROENTERITISAdenovirus 40/41 Clinical IllnessIncubation: 7 - 8 daysDuration: 8 - 12 daysDiarrhea predominates
VIRAL GASTROENTERITISAdenovirus 40/41 EpidemiologySecond leading cause of cases (5-20%) and hospitalizations in infants Occurs year around; no seasonal peakPredominates in late fall and winterAsymptomatic or mild illness in older children, adultsTransmission: person-to-person
VIRAL GASTROENTERITISAstrovirusesFamily AstroviridaessRNA, non-enveloped; 28 - 30 nm> 5 serotypes?
VIRAL GASTROENTERITISAstrovirus Clinical IllnessIncubation: 3 - 4 daysDuration: < 5 daysIllness milder than RotavirusDiarrhea and low grade fever predominate
VIRAL GASTROENTERITISAstrovirus EpidemiologyCommunity impact uncertainMost common in < 3 years of age; often asymptomaticMild illness in adultsWinter peak in temperate climatesTransmission: person-to-person; water/food?
GASTROENTERITIS VIRUSESPATHOGENETIC CHARACTERISTICSType of infection: acute, localizedGastrointestinal tract is target organIncubation period: generally short, 1-4daysException is adenovirus type 40 and 41infections (7-8days)Mechanism of transmission: person-to-person via fecal-oral route; food-and water-borne Viruses environmentally stableFrequency of inapparent infections: low (except Astrovirus) for primary infection; increase with re-infection (Rotavirus) Symptomatic re-infections: commonImplies poor long-term immunityProlonged virus shedding: common with adenovirus; can occur with rotavirus Illnesses often more severe in compromised hosts
VIRAL GASTROENTERITISLaboratory Diagnosis
VIRAL GASTROENTERITISGuidelines for Specimen CollectionCollect stool within 48 hours after onsetBulk sample; no preservatives; rectal swabs of little valueRefrigerate at 4C; do not freeze
VIRAL GASTROENTERITISLaboratory Testing AvailableRotavirus: EIA*, LA, EM, RT-PCRAdenovirus 40/41: EIA*Norovirus: RT-PCR*, EMAstrovirus: RT-PCR*, EM
* Method of Choice
VIRAL GASTROENTERITISTreatment
Fluid and electrolyte replacement
VIRAL GASTROENTERITISPreventionHand washing; hygiene; cohorting infantsRotavirus vaccineLive, attenuated, reassortant, oral vaccineDirected against group A, serotypes 1 - 4Universal administration 2, 4 and 6 monthsUSE OF THE VACCINE HAS BEEN SUSPENDED DUE TO CLINICAL COMPLICATIONS!
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