an acute gastroenteritis outbreak caused by gii 17 norovirus in jiangsu province china

Accepted Manuscript Title: An acute gastroenteritis outbreak caused by GII.17 norovirus in Jiangsu province, China Author: Chao Shi Wei-Hong Feng Ping Shi Jing Ai Hong-Xia Guan Dan Sha Qian Geng Jun Mei Shan-hui Chen Yong Xiao Yan-Hua Qian PII: DOI: Reference: S1201-9712(16)31047-5 http://dx.doi.org/doi:10.1016/j.ijid.2016.05.004 IJID 2609 To appear in: International Journal of Infectious Diseases Received date: Revised date: Accepted date: 8-1-2016 30-4-2016 4-5-2016 Please cite this article as: Shi C, Feng W-H, Shi P, Ai J, Guan H-X, Sha D, Geng Q, Mei J, Chen S-h, Xiao Y, Qian Y-H, An acute gastroenteritis outbreak caused by GII.17 norovirus in Jiangsu province, China, International Journal of Infectious Diseases (2016), http://dx.doi.org/10.1016/j.ijid.2016.05.004 This is a PDF file of an unedited manuscript that has been accepted for publication As a service to our customers we are providing this early version of the manuscript The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain Highlights A rare norovirus genotype GII.17 variant caused outbreaks in a ip t high school in Wuxi, Jiangsu Province China in the winter of cr 2014 us The outbreak is caused by the first case which was affected outside the school an Epidemic curve and epidemical investigation indicated this outbreak was a point source type initially, followed by secondary M person-to-person transmission Ac ce p te cross-contamination d The water cooler in the classroom increased the risk of Page of 14 An acute gastroenteritis outbreak caused by GII.17 ip t norovirus in Jiangsu province, China cr Chao Shi a, 1, Wei-Hong Feng a, 1, Ping Shi a, 1, Jing Ai b, Hong-Xia Guana, , Dan Shaa, ,Qian Geng a, Jun Mei a, Shan-hui Chen a , Yong Xiaoa*, Yan-Hua Qian a* Wuxi Center for Disease Control and Prevention, Wuxi, Jiangsu 214023, China b Jiangsu Center for Disease Control and Prevention, Nanjing, Jiangsu 210009, China Chao Shi, Ping Shi, and Wei-Hong Feng contributed equally to this study us a * an Correspondence to: wxcdcjkb@sina.cn and wxcdcxy@163.com M SUMMARY Noroviruses (NoVs) are a common cause of acute gastroenteritis (AGE) around d the world; however, reports of GII.17 NoVs-caused outbreak are rare Here we report te an outbreak caused by GII.17 norovirus in a senior high school in Wuxi, Jiangsu Ac ce p province, China We carried out the epidemiological investigation, pathogen detection and case-control study Epidemiological data combined with the epidemic curve indicated this outbreak was a point source type initially, followed by secondary transmission We identified the first case is most likely the source of the outbreak Risk analysis showed exposure to patients and sharing communal water cooler were associated with the spread of infection Sequence analysis of GII-positive sample confirmed that the norovirus GII.17 variants was etiological agent of this outbreak Key words: Noroviruses; Molecular epidemiology; Disease outbreak Page of 14 Introduction ip t A meta-analysis published in 2014 suggests that norovirus (NoV) causes almost a fifth of all cases of acute gastroenteritis worldwide Genogroups I, II, and IV, cr including at least 25 genotypes, are responsible for human infections For norovirus, other fomites are important transmission vehicles us the faecal–oral route is the leading transmission mode Contaminated water, food or an Over the past two decades, new variants of GII.4 were estimated to be 3, Prior to 2014, M responsible for 55–85% of NoV-associated outbreaks worldwide reports on acute gastroenteritis caused by norovirus GII.17 were rare5, It was noted d that during 2014–15 NoV epidemic season, a new GII.17 variant emerged locally in te Guangdong and Jiangsu Province of China and Japan 7-9 Ac ce p On December 11, 2014, it was reported that 57 students from a senior high school in Wuxi city, China had developed acute diarrhea and vomiting Rectal swab samples from nine of the patients were found to be positive for NoV GII.17 using reverse transcriptase PCR (RT-PCR) In order to provide effective control measures, we surveyed the outbreak to verify additional cases and the source of infection, vehicle for infection, and mode of transmission Case report For the epidemiology investigation, suspected cases were defined as vomiting that accompanied nausea, diarrhea, abdominal pain, or fever Confirmed cases Page of 14 included the same criteria with positive laboratory confirmation of the norovirus Non-cases were defined as students or staffs without symptoms of diarrhea or ip t vomiting at the longest incubation period of norovirus infection (72 h) after exposure to suspected risk factors All of the case students (suspected and confirmed) and cr asymptomatic students at a ratio of 1:1 matched by class and age (±1 year) were us enrolled in the case–control study According to the "Surveillance Program for the Viral Diarrhea Outbreak of an Jiangsu Province ", we totally collected 30 rectal swabs, 10 from case group, 10 from cafeteria food handlers and 10 from non-case group For highly transmissible M environmental contagious agents, surface swabs from kitchen rags, kitchen cabinet, cafeteria tables and communal water cooler spigot in the affected classroom were te d collected 10 L water sample from communal water cooler in every affected classroom was also collected Water samples were first concentrated by Nanoceram Ac ce p electropositive filter (Argonide Corp, USA) and Centricon Plus-70 centrifugal filter (Millipore corp, USA) before RNA extraction10 Stool samples and environmental samples were tested for the presence of pathogenic bacteria and intestinal viruses The bacterial pathogens were tested according to the technical procedures of diarrheal pathogenic spectrum surveillance formulated by the China CDC to process bacterial isolation, culture and purification After RNA extraction using Roche MagNA Pure LC instrument (Roche Applied Science, IN, USA), the swabs and concentrated water samples were tested for viral agent by Real-time reverse transcription PCR on ABI7500 using corresponding detection kit (shanghai ZJ Bio-tech Corp, Shanghai, Page of 14 China) Conditional logistical regression analysis was used to calculate odds ratios (OR) ip t and 95% confidence intervals (CI) of various risk-factors to predict cases at a significance level of p< 0.05 Statistical analyses were performed with SPSS for cr Windows, version 17.0 (SPSS Inc, USA) us On December 14, 2014, the earliest suspected norovirus case, which is an extern student of grade three, had vomited several times in public areas, including the an classroom and the washroom Within the next three days, 27 cases occurred which were mainly located in the fourth floor (12 cases) and third floor (9 cases).Thus, the M epidemic reached its first incidence peak (Figure 1) Decrease in cases followed after the implementation of control measures such as quarantine and disinfection However, te d several days later, attack rate peaked again on December 25th In contrast with first peak, this time student cases were mainly distributed in the second floor (12 cases) Ac ce p and third floor (5 cases) To control further spread of disease, the school was closed temporarily As a result, the outbreak came to an end on the last day of 2014 (Figure 1) According to the epidemiological questionnaire results, up to December 31, 2014, totally 57 of 2209 people were recorded as cases with the attack rate of 2.58% The cases were all students with age ranged from 16 to 19 The main symptoms were diarrhea (80.7%), vomiting (64.9%), abdominal cramp (47.4%) and fever (7.0%) The 57 student cases were distributed across grades and 21 classes The attack rate of students in grades (5.0%, 35/700) was significantly higher than those in grades Page of 14 (2.0%, 13/650) and grade (1.46%, 9/616) (p< 0.05) Risk factor analysis showed that, the incidence of gastroenteritis among those ip t exposure to patients were the 4.04-fold (95% CI: 1.80-9.06) higher than those with no contact with infected persons, and the incidence of gastroenteritis among those who cr drinking water from water cooler was 2.44-fold (95% CI: 1.13-5.26) higher than those us without drinking bottled water (p< 0.05) (Table 1) Nine of 30 rectal swab samples tested positive for norovirus GII in the outbreak an Samples from the water and body surface were detected negative for norovirus in the outbreaks Those GII-positive samples were further genotyped by semi-nested PCR M and sequencing11, 12 Phylogenetic analysis showed the strains isolated in this outbreak were grouped with the GII.17 strain isolated from Guangdong province (KP718639, Ac ce p Discussion te d 2014), Taiwan (KJ156329, 2013) and Japan (AB983218, 2014) Previous epidemiologic data suggest that in the past years, GII.4 Sydney 2012 has been the major circulating norovirus genotype worldwide4, 13 GII.17 cases were only sporadically reported In Africa, Asia, Europe, North America and South America14 However, a sharp increase in the number of cases caused by this novel virus had been observed during the 2014/2015 winter season in Japan and Guangdong province in China8, Here we described an outbreak caused by GII.17 norovirus in one high school in Wuxi, Jiangsu province Norovirus infection is characterized by the sudden onset of vomiting or diarrhea or both symptoms Human experimental infection studies with norovirus show that Page of 14 the predominant symptom can vary from person to person In this norovirus outbreak, the diarrhea and vomiting were predominately clinical features ip t Norovirus is extremely contagious and humans are the only known reservoir for human norovirus Transmission occurs via fecal-oral pathways by four general routes: cr direct person-to-person, foodborne, waterborne or through environmental fomites us Negative results for norovirus in water samples and kitchen surface specimens did not support the hypothesis of food-borne or water-borne origin of the outbreak As the act an of vomiting generates an infectious aerosol, airborne transmission of norovirus from the first case who vomited in the classroom most probably initiated the outbreak In M the classrooms where vomiting occurred or nearby students (fourth floor and third floor) became ill in a much shorter period of time than students in classrooms far from te d where the vomiting occurred (first floor and second floor) in the initial 96 hours This phenomenon was compatible with person-to-person transmission mode The Ac ce p descriptive epidemiologic investigation combined with epidemic curve supported that this was a point source outbreak with secondary transmission toward to the end, and the first case is most likely the source of the outbreak According to the analyses of risk factors, exposure to patients and sharing water cooler in the classroom increased the risk of the transmission of the norovirus, which suggesting transmission occurred primarily via direct person-to-person and secondly through environmental fomites route We speculated the spigot of water cooler may serve as the transmission vehicle of infection despite it was tested negative for norovirus Page of 14 Sequence analysis of GII-positive sample suggested that the norovirus GII.17 variants in this outbreak were highly homologous to that isolated strains in ip t Guangdong, Japan and Taiwan The prevalent of this novel norovirus may be attribute to their wide spectrum of HBGA-associated susceptibility like GII.4 norovirus do, so us cr it might have the potential to spread globally in the near future15 an Ethical Approval: This outbreak investigation was conducted by public health agencies as part of their legally authorized mandate and was therefore considered a M minimal risk research and was exempted from ethical approval by the institutional te d review boards Acknowledgments: This work was supported by the Jiangsu Province Scientific Ac ce p Project of Preventive Medicine (Y2015006) and Fund for scientific and technological development of Wuxi (CSE31N1301 and CSE31N1515) Conflicts of Interest: The authors declare no conflict of interest Page of 14 References Ahmed SM, Hall AJ, Robinson AE, Verhoef L, Premkumar P, Parashar UD, ip t Koopmans M, Lopman BA Global prevalence of norovirus in cases of gastroenteritis: a systematic review and meta-analysis The Lancet Infectious Updated norovirus outbreak management and disease prevention guidelines us cr diseases 2014;14:725-30 MMWR Recommendations and reports : Morbidity and mortality weekly an report Recommendations and reports / Centers for Disease Control 2011;60:1-18 Emergence of new norovirus strain GII.4 Sydney United States, 2012 M MMWR Morbidity and mortality weekly report 2013;62:55 d van Beek J, Ambert-Balay K, Botteldoorn N, Eden JS, Fonager J, Hewitt J, te Iritani N, Kroneman A, Vennema H, Vinje J, White PA, Koopmans M Ac ce p Indications for worldwide increased norovirus activity associated with emergence of a new variant of genotype II.4, late 2012 Euro surveillance : bulletin Europeen sur les maladies transmissibles = European communicable disease bulletin 2013;18:8-9 de Andrade Jda S, Rocha MS, Carvalho-Costa FA, Fioretti JM, Xavier Mda P, Nunes ZM, Cardoso J, Fialho AM, Leite JP, Miagostovich MP Noroviruses associated with outbreaks of acute gastroenteritis in the State of Rio Grande Sul, Brazil, 2004-2011 Journal of clinical virology : the official publication of the Pan American Society for Clinical Virology 2014;61:345-52 Page of 14 El Qazoui M, Oumzil H, Baassi L, El Omari N, Sadki K, Amzazi S, Benhafid M, El Aouad R Rotavirus and norovirus infections among acute ip t gastroenteritis children in Morocco BMC infectious diseases 2014;14:300 Fu J, Ai J, Jin M, Jiang C, Zhang J, Shi C, Lin Q, Yuan Z, Qi X, Bao C, Tang F, cr Zhu Y Emergence of a new GII.17 norovirus variant in patients with acute us gastroenteritis in Jiangsu, China, September 2014 to March 2015 Euro surveillance : bulletin Europeen sur les maladies transmissibles = European an communicable disease bulletin 2015;20 Matsushima Y, Ishikawa M, Shimizu T, Komane A, Kasuo S, Shinohara M, M Nagasawa K, Kimura H, Ryo A, Okabe N, Haga K, Doan YH, Katayama K, Shimizu H Genetic analyses of GII.17 norovirus strains in diarrheal disease te d outbreaks from December 2014 to March 2015 in Japan reveal a novel polymerase sequence and amino acid substitutions in the capsid region Euro Ac ce p surveillance : bulletin Europeen sur les maladies transmissibles = European communicable disease bulletin 2015;20 Lu J, Sun L, Fang L, Yang F, Mo Y, Lao J, Zheng H, Tan X, Lin H, Rutherford S, Guo L, Ke C, Hui L Gastroenteritis Outbreaks Caused by Norovirus GII.17, Guangdong Province, China, 2014-2015 Emerging infectious diseases 2015;21:1240-2 10 Ikner LA, Soto-Beltran M, Bright KR New method using a positively charged microporous filter and ultrafiltration for concentration of viruses from tap water Applied and environmental microbiology 2011;77:3500-6 10 Page 10 of 14 11 Kojima S, Kageyama T, Fukushi S, Hoshino FB, Shinohara M, Uchida K, Natori K, Takeda N, Katayama K Genogroup-specific PCR primers for of Norwalk-like viruses Journal of virological 2002;100:107-14 Puustinen L, Blazevic V, Huhti L, Szakal ED, Halkosalo A, Salminen M, cr 12 methods ip t detection children in Finland between 1994 13 and 2007 Epidemiol Infect an 2012;140:268-75 us Vesikari T Norovirus genotypes in endemic acute gastroenteritis of infants and Vega E, Barclay L, Gregoricus N, Shirley SH, Lee D, Vinje J Genotypic and M epidemiologic trends of norovirus outbreaks in the United States, 2009 to 2013 Journal of clinical microbiology 2014;52:147-55 d Verhoef L, Hewitt J, Barclay L, Ahmed SM, Lake R, Hall AJ, Lopman B, te 14 Kroneman A, Vennema H, Vinje J, Koopmans M Norovirus genotype profiles Ac ce p associated with foodborne transmission, 1999-2012 Emerging infectious diseases 2015;21:592-9 15 Zhang XF, Huang Q, Long Y, Jiang X, Zhang T, Tan M, Zhang QL, Huang ZY, Li YH, Ding YQ, Hu GF, Tang S, Dai YC An outbreak caused by GII.17 norovirus with a wide spectrum of HBGA-associated susceptibility Scientific reports 2015;5:17687 11 Page 11 of 14 Table Risk factors analysis table 57 57 Yes 44(77.2%) 26(45.6%) No 13(22.8%) 31(54.4%) 57 57 Yes 40(70.2%) 28(49.1%) No 17(29.8%) 29(50.9%) 57 56 Yes 18(31.6%) 34(60.7%) No 39(68.4%) 22(39.3%) 57 57 Yes 28(49.1%) 23(40.4%) No 29(50.9%) 34(59.6%) cooler in the classroom Washing hand after toilet Sharing a toilet Eating cold food 57 M Drinking water from water No 41(71.9%) 36(63.2%) 57 57 te 2(3.5%) 55(96.5%) Ac ce p No Source of drinking water 21(36.8%) d 16(28.1%) Yes 0.001 4.04(1.80-9.06) 1.00(reference) 0.022 2.44(1.13-5.26) 1.00(reference) 0.002 0.346 0.30(0.14-0.65) 1.00(reference) 1.43(0.68-3.00) 1.00(reference) 57 Yes Drinking unboiled water OR(95%CI) ip t History of contacting with cases P-values a cr control n (%) us case n (%) an Variables 4(7.0%) 0.317 0.67(0.30-1.47) 1.00(reference) 0.402 53(93.0%) 0.48(0.09-2.74) 1.00(reference) 57 57 Bottled water 17(29.8%) 27(47.4%) Boiled water from dormitory 21(36.8%) 14(24.6%) — Both of the above water 19(33.3%) 16(28.1%) — 0.140 — a Conditional logistical regression analysis 12 Page 12 of 14 Ac ce p te d M an us cr ip t Fig Distribution of cases grouped by floor by date of outbreak onset The cases were plotted by onset date and grouped by the floor where they located to produce an epidemic curve showing how the outbreak had spread 13 Page 13 of 14 Ac ce pt ed M an us cr i Figure Page 14 of 14 ...Highlights A rare norovirus genotype GII. 17 variant caused outbreaks in a ip t high school in Wuxi, Jiangsu Province China in the winter of cr 2014 us The outbreak is caused by the first case... cooler in the classroom increased the risk of Page of 14 An acute gastroenteritis outbreak caused by GII. 17 ip t norovirus in Jiangsu province, China cr Chao Shi a, 1, Wei-Hong Feng a, 1, Ping Shi... on acute gastroenteritis caused by norovirus GII. 17 were rare5, It was noted d that during 2014–15 NoV epidemic season, a new GII. 17 variant emerged locally in te Guangdong and Jiangsu Province