Scientific letter
An outbreak of acute norovirus gastroenteritis in a boarding school in Zamora, Spain
Brote de gastroenteritis aguda por norovirus en un colegio interno en Zamora, España
Míriam Albert-Hernándeza,b,c,
, Isabel Martínez-Pinod, Juan Emilio Antón-Ruedae, Ma Fe Brezmes-Valdiviesof
Corresponding author
a Unidad de Microbiología, Complejo Asistencial de Zamora, Hospital Virgen de la Concha, Avenida de Requejo, 35, 49002 Zamora, Spain
b Escuela Universitaria de Enfermería en Zamora, Centro Adscrito a la Universidad de Salamanca, Avenida Requejo, 21, 1 49012 Zamora, Spain
c Facultad de Farmacia, Universidad de Salamanca, Campus Miguel de Unamuno, C/Lic. Méndez Nieto, s/n, 37007 Salamanca, Spain
d Sección de Epidemiología, Servicio Territorial de Sanidad y Bienestar Social, Delegación Territorial de Zamora, Junta de Castilla y León, Pza. de Alemania, 1, CP 49014 Zamora, Spain
e Servicio Territorial de Sanidad y Bienestar Social, Delegación Territorial de Zamora, Junta de Castilla y León, Pza. de Alemania, 1, C.P. 49014 Zamora, Spain
f Unidad de Microbiología, Complejo Asistencial de Zamora, Hospital Virgen de la Concha, Avenida de Requejo, 35, 49002 Zamora, Spain
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Méndez Nieto, s/n, 37007 Salamanca, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Sección de Epidemiología, Servicio Territorial de Sanidad y Bienestar Social, Delegación Territorial de Zamora, Junta de Castilla y León, Pza. de Alemania, 1, CP 49014 Zamora, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "Servicio Territorial de Sanidad y Bienestar Social, Delegación Territorial de Zamora, Junta de Castilla y León, Pza. de Alemania, 1, C.P. 49014 Zamora, Spain" "etiqueta" => "e" "identificador" => "aff0025" ] 5 => array:3 [ "entidad" => "Unidad de Microbiología, Complejo Asistencial de Zamora, Hospital Virgen de la Concha, Avenida de Requejo, 35, 49002 Zamora, Spain" "etiqueta" => "f" "identificador" => "aff0030" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Brote de gastroenteritis aguda por norovirus en un colegio interno en Zamora, España" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1125 "Ancho" => 1733 "Tamanyo" => 145357 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Number of cases of gastroenteritis by date of onset of symptoms, Zamora, October 2014 (epidemic curve).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Norovirus (NoV) is the leading cause of outbreaks of gastroenteritis in humans worldwide, especially in children in the post-rotavirus vaccine era.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> Significantly, the frequency has also increased in institutionalized and hospitalized population, immunocompromised patients and extreme ages.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> Investigations of outbreaks have shown that the majority of transmissions are by direct contact with individuals carrying the virus, water, aerosols, contaminated food, and due to environmental contamination.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> The incubation period is short (12–48<span class="elsevierStyleHsp" style=""></span>h), showing a higher incidence in autumn and winter. Typical clinical manifestations are vomiting and diarrhoea, and paediatric patients are more liable to have dehydration requiring hospitalization.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> Genetically, NoV has been classified into six genogroups (genogroup I [GI] to genogroup VI [GVI]), of which GI, GII, and GIV can infect humans.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> The genogroups are further classified into 9 GI, 22 GII, and 2 GIV genotypes.<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">4,5</span></a> Although the GII.4 genotype is currently responsible for 60–90% of outbreaks worldwide,<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> new GII.4 variants emerge every 2–3 years and become the dominant strains during the new season.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">On October 2014 an outbreak of acute gastroenteritis in a boarding school in Zamora (Castile and Leon, Spain) was reported to the local public health authority (LPHA). An outbreak investigation was conducted to identify the most likely causative agent and mode of transmission and to implement control measures. Given the importance of an accurate and early result, we used for the first time at our Laboratory of Microbiology molecular techniques for the NoV detection and we assessed, at the same time, their utility for the diagnosis of subsequent outbreaks.</p><p id="par0015" class="elsevierStylePara elsevierViewall">LPHA inspected the school premises and conducted a retrospective analysis using a structured questionnaire on demographic data, symptoms, food consumption and other possible risk factors. An outbreak case was defined as a person attending the affected institution who presented diarrhoea, vomiting or abdominal pain from 14 to 16 October 2014.</p><p id="par0020" class="elsevierStylePara elsevierViewall">A total of 36 students (69.4% male, median age 15 years (12–19)) developed symptoms, whereas staff was not affected. The overall attack rate was 19.9% with no significant sex-related differences. The most frequent symptoms were abdominal cramps (97.2%), vomiting (91.7%) and neurological symptoms such as headache (83.3%). Diarrhoea (52.8%) and fever (19.4%) were less frequent. <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a> shows the number of cases by date of onset of symptoms. The outbreak was self-limiting in 3 days and nobody was hospitalised.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">Stool samples from 2 cases were screened for the most frequent enteropathogenic bacteria by selective and differential media and for rotavirus and enteric adenoviruses antigen by an immunochromatographic technique (ICT) (Balea Norovirus<span class="elsevierStyleSup">®</span>). Simultaneously, samples were tested by a real-time reverse transcription polymerase chain reaction (RT RT-PCR) (Xpert<span class="elsevierStyleSup">®</span> Norovirus, Cepheid) for qualitative detection and differentiation of NoV GI/GII and by an ICT for the same genogroups. In both samples NoV ICT was negative but the RT RT-PCR detected NoV GII. <span class="elsevierStyleItalic">Salmonella, Shigella, Yersinia, Aeromonas, Hafnia</span> and <span class="elsevierStyleItalic">Campylobacter</span> and viral enteropathogens were discarded. Food samples were negative for enteropathogenic bacteria (no viruses were studied) at the LPH laboratory.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Different outbreaks due to NoV in closed institutions have been reported in Spain. Navarro et al.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> described NoV GII affecting patients, staff members, and their relatives in a long-term-care unit and suggesting a person-to-person spread. The same genogroup was detected in Majorca, associated with the children's club of a hotel.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a> A food-borne NoV outbreak was reported among staff at a hospital in Barcelona<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a> and a water-borne one in a factory in the Basque Country.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Epidemiological features, microbiological results and no isolation of other pathogens confirmed that the outbreak was caused by NoV GII, with probable person-to-person transmission. This was the first time a NoV outbreak in Zamora was laboratory confirmed, although source remained unclear. We emphasize that the presence of NoV should always be suspected and investigated in gastroenteritis outbreaks including those of closed institutions in the absence of the usual pathogens. Given the low sensitivity of the ICTs for NoV detection, molecular techniques could be prioritized in case of epidemiological suspicion. Therefore, we recommend the implementation of molecular techniques, with high sensitivity and specificity, no time-consuming management and fast results, despite the high cost, to determine the actual frequency of NoV both on sporadic cases as well as outbreaks.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Funding</span><p id="par0040" class="elsevierStylePara elsevierViewall">No funding has been received for this research.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Conflict of interest</span><p id="par0045" class="elsevierStylePara elsevierViewall">No conflict of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Funding" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Conflict of interest" ] 2 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1125 "Ancho" => 1733 "Tamanyo" => 145357 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Number of cases of gastroenteritis by date of onset of symptoms, Zamora, October 2014 (epidemic curve).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0055" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Worldwide molecular epidemiology of norovirus infection" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "S.Y. 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| Year/Month | Html | Total | |
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| 2024 November | 6 | 0 | 6 |
| 2024 October | 21 | 9 | 30 |
| 2024 September | 60 | 2 | 62 |
| 2024 August | 29 | 5 | 34 |
| 2024 July | 55 | 9 | 64 |
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| 2024 May | 12 | 1 | 13 |
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| 2024 February | 22 | 3 | 25 |
| 2024 January | 21 | 3 | 24 |
| 2023 December | 20 | 9 | 29 |
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| 2023 September | 9 | 1 | 10 |
| 2023 August | 25 | 1 | 26 |
| 2023 July | 20 | 9 | 29 |
| 2023 June | 21 | 2 | 23 |
| 2023 May | 19 | 12 | 31 |
| 2023 April | 22 | 0 | 22 |
| 2023 March | 15 | 0 | 15 |
| 2023 February | 17 | 5 | 22 |
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| 2022 December | 13 | 9 | 22 |
| 2022 November | 32 | 12 | 44 |
| 2022 October | 23 | 11 | 34 |
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| 2022 August | 30 | 10 | 40 |
| 2022 July | 25 | 7 | 32 |
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| 2022 May | 34 | 11 | 45 |
| 2022 April | 36 | 15 | 51 |
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| 2021 October | 26 | 20 | 46 |
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| 2021 July | 37 | 17 | 54 |
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| 2021 May | 24 | 10 | 34 |
| 2021 April | 66 | 38 | 104 |
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| 2021 February | 35 | 11 | 46 |
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| 2020 December | 18 | 6 | 24 |
| 2020 November | 15 | 13 | 28 |
| 2020 October | 23 | 8 | 31 |
| 2020 September | 36 | 11 | 47 |
| 2020 August | 26 | 6 | 32 |
| 2020 July | 19 | 9 | 28 |
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| 2020 May | 31 | 8 | 39 |
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| 2020 March | 18 | 10 | 28 |
| 2020 February | 16 | 4 | 20 |
| 2020 January | 20 | 3 | 23 |
| 2019 December | 24 | 6 | 30 |
| 2019 November | 16 | 2 | 18 |
| 2019 October | 13 | 5 | 18 |
| 2019 September | 27 | 10 | 37 |
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| 2018 December | 12 | 5 | 17 |
| 2018 November | 16 | 1 | 17 |
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| 2018 September | 38 | 4 | 42 |
| 2018 August | 49 | 1 | 50 |
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| 2018 June | 6 | 0 | 6 |
| 2018 May | 15 | 4 | 19 |
| 2018 April | 15 | 2 | 17 |
| 2018 March | 6 | 1 | 7 |
| 2018 February | 12 | 2 | 14 |
| 2018 January | 12 | 0 | 12 |
| 2017 December | 16 | 1 | 17 |
| 2017 November | 13 | 2 | 15 |
| 2017 October | 12 | 4 | 16 |
| 2017 September | 2 | 1 | 3 |
| 2017 August | 1 | 0 | 1 |
| 2017 June | 2 | 1 | 3 |
| 2017 May | 12 | 7 | 19 |
| 2017 April | 25 | 12 | 37 |
| 2017 March | 2 | 0 | 2 |
| 2017 February | 8 | 5 | 13 |
| 2017 January | 6 | 3 | 9 |
| 2016 December | 2 | 4 | 6 |
| 2016 November | 3 | 11 | 14 |
| 2016 October | 8 | 10 | 18 |
| 2016 September | 5 | 5 | 10 |
| 2016 August | 2 | 9 | 11 |
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