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Disease transmission and passenger behaviors during a high morbidity Norovirus outbreak on a cruise ship, January 2009.
Clin Infect Dis. 2011 May; 52(9):1116-22.CI

Abstract

BACKGROUND

Norovirus continues to pose a significant burden on cruise ships, causing an average of 27 confirmed outbreaks annually over the past 5 years. In January 2009, the report of a suspected norovirus outbreak among passengers on a cruise ship prompted an investigation.

METHODS

A retrospective cohort study among passengers was conducted on board the ship. Questionnaires about health care-seeking behaviors, hygiene practices, and possible norovirus exposures were placed in every cabin. Stool samples from several ill passengers were tested for norovirus by quantitative reverse-transcriptase polymerase chain reaction (RT-qPCR) and confirmed by sequence analysis.

RESULTS

Of 1842 passengers, 1532 (83.2%) returned questionnaires, and 236 (15.4% of participants) met the case definition. Of these, 95 (40%) did not report to the infirmary. Case passengers were significantly more likely to have an ill cabin mate (relative risk [RR] = 3.0; P < .01) and to have witnessed vomiting during boarding (RR = 2.8; P = .01). Over 90% of all passengers reported increased hand hygiene practices following the outbreak; 38% of ill passengers and 11% of well passengers decreased participation in public activities. Of 14 samples tested, 12 were positive for norovirus by RT-qPCR; 5 of these were confirmed by sequence analysis and typed as GII.4 Minerva.

CONCLUSIONS

Person-to-person transmission, including an incident of public vomiting during boarding, likely contributed to this high morbidity outbreak. Infirmary surveillance detected only 60% of acute gastroenteritis (AGE) cases involved in this outbreak. Adjustments to outbreak reporting thresholds may be needed to account for incomplete voluntary AGE reporting and to more rapidly implement control measures.

Authors+Show Affiliations

National Center for Immunization, and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA. mwikswo@cdc.govNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info available

Pub Type(s)

Journal Article
Research Support, U.S. Gov't, P.H.S.

Language

eng

PubMed ID

21429864

Citation

Wikswo, Mary E., et al. "Disease Transmission and Passenger Behaviors During a High Morbidity Norovirus Outbreak On a Cruise Ship, January 2009." Clinical Infectious Diseases : an Official Publication of the Infectious Diseases Society of America, vol. 52, no. 9, 2011, pp. 1116-22.
Wikswo ME, Cortes J, Hall AJ, et al. Disease transmission and passenger behaviors during a high morbidity Norovirus outbreak on a cruise ship, January 2009. Clin Infect Dis. 2011;52(9):1116-22.
Wikswo, M. E., Cortes, J., Hall, A. J., Vaughan, G., Howard, C., Gregoricus, N., & Cramer, E. H. (2011). Disease transmission and passenger behaviors during a high morbidity Norovirus outbreak on a cruise ship, January 2009. Clinical Infectious Diseases : an Official Publication of the Infectious Diseases Society of America, 52(9), 1116-22. https://doi.org/10.1093/cid/cir144
Wikswo ME, et al. Disease Transmission and Passenger Behaviors During a High Morbidity Norovirus Outbreak On a Cruise Ship, January 2009. Clin Infect Dis. 2011;52(9):1116-22. PubMed PMID: 21429864.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Disease transmission and passenger behaviors during a high morbidity Norovirus outbreak on a cruise ship, January 2009. AU - Wikswo,Mary E, AU - Cortes,Jennifer, AU - Hall,Aron J, AU - Vaughan,George, AU - Howard,Christopher, AU - Gregoricus,Nicole, AU - Cramer,Elaine H, Y1 - 2011/03/22/ PY - 2011/3/25/entrez PY - 2011/3/25/pubmed PY - 2011/8/16/medline SP - 1116 EP - 22 JF - Clinical infectious diseases : an official publication of the Infectious Diseases Society of America JO - Clin Infect Dis VL - 52 IS - 9 N2 - BACKGROUND: Norovirus continues to pose a significant burden on cruise ships, causing an average of 27 confirmed outbreaks annually over the past 5 years. In January 2009, the report of a suspected norovirus outbreak among passengers on a cruise ship prompted an investigation. METHODS: A retrospective cohort study among passengers was conducted on board the ship. Questionnaires about health care-seeking behaviors, hygiene practices, and possible norovirus exposures were placed in every cabin. Stool samples from several ill passengers were tested for norovirus by quantitative reverse-transcriptase polymerase chain reaction (RT-qPCR) and confirmed by sequence analysis. RESULTS: Of 1842 passengers, 1532 (83.2%) returned questionnaires, and 236 (15.4% of participants) met the case definition. Of these, 95 (40%) did not report to the infirmary. Case passengers were significantly more likely to have an ill cabin mate (relative risk [RR] = 3.0; P < .01) and to have witnessed vomiting during boarding (RR = 2.8; P = .01). Over 90% of all passengers reported increased hand hygiene practices following the outbreak; 38% of ill passengers and 11% of well passengers decreased participation in public activities. Of 14 samples tested, 12 were positive for norovirus by RT-qPCR; 5 of these were confirmed by sequence analysis and typed as GII.4 Minerva. CONCLUSIONS: Person-to-person transmission, including an incident of public vomiting during boarding, likely contributed to this high morbidity outbreak. Infirmary surveillance detected only 60% of acute gastroenteritis (AGE) cases involved in this outbreak. Adjustments to outbreak reporting thresholds may be needed to account for incomplete voluntary AGE reporting and to more rapidly implement control measures. SN - 1537-6591 UR - https://www.unboundmedicine.com/medline/citation/21429864/Disease_transmission_and_passenger_behaviors_during_a_high_morbidity_Norovirus_outbreak_on_a_cruise_ship_January_2009_ L2 - https://academic.oup.com/cid/article-lookup/doi/10.1093/cid/cir144 DB - PRIME DP - Unbound Medicine ER -