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"documento" => "simple-article" "crossmark" => 1 "subdocumento" => "crp" "cita" => "Med Clin. 2015;144:204-6" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 82 "formatos" => array:2 [ "HTML" => 63 "PDF" => 19 ] ] "en" => array:12 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Brief report</span>" "titulo" => "Norovirus outbreaks in geriatric centres: Importance of an early detection" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "204" "paginaFinal" => "206" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Brotes de infección por norovirus en centros geriátricos: importancia de una detección precoz" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Antonio Moreno, Sandra Manzanares-Laya, Efren Razquin, Susana Guix, Ángela Domínguez, Mercedes de Simón" "autores" => array:7 [ 0 => array:2 [ "nombre" => "Antonio" "apellidos" => "Moreno" ] 1 => array:2 [ "nombre" => "Sandra" "apellidos" => "Manzanares-Laya" ] 2 => array:2 [ "nombre" => "Efren" "apellidos" => "Razquin" ] 3 => array:2 [ "nombre" => "Susana" "apellidos" => "Guix" ] 4 => array:2 [ "nombre" => "Ángela" "apellidos" => "Domínguez" ] 5 => array:2 [ "nombre" => "Mercedes" "apellidos" => "de Simón" ] 6 => array:1 [ "colaborador" => "Working Group for the Study of Acute Viral Gastroenteritis Outbreaks in Catalonia" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0025775314005685" "doi" => "10.1016/j.medcli.2014.05.041" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0025775314005685?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020615000893?idApp=UINPBA00004N" "url" => "/23870206/0000014400000005/v1_201511080018/S2387020615000893/v1_201511080018/en/main.assets" ] "en" => array:12 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Editorial article</span>" "titulo" => "<span class="elsevierStyleItalic">Norovirus</span> and its increasing clinical importance" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "207" "paginaFinal" => "208" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Miriam Hernández Porto, María Lecuona" "autores" => array:2 [ 0 => array:4 [ "nombre" => "Miriam" "apellidos" => "Hernández Porto" "email" => array:1 [ 0 => "portomiri@hotmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "María" "apellidos" => "Lecuona" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Microbiología y Medicina Preventiva, Hospital Universitario de Canarias, La Laguna, Tenerife, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "<span class="elsevierStyleItalic">Norovirus</span> y su creciente importancia clínica" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Over the last years, there has been an increasing acknowledgement of the impact on people's health of infections by <span class="elsevierStyleItalic">Norovirus</span>. In the U.S.A. it is considered the most frequent cause of gastroenteritis, producing 19–21 millions of infections, 56,000–71,000 hospitalisations, and 570–800 deaths per year.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">1</span></a> Moreover, <span class="elsevierStyleItalic">Norovirus</span> is considered the main cause of outbreaks and sporadic cases of nonbacterial gastroenteritis in patients of all ages.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">2</span></a> In industrialised countries, the incidence of this condition among ambulatory patients is estimated to be between 21 and 92 every 10,000 inhabitants, with hospitalisation rates from 1.2 to 2.4 every 10,000 inhabitants and mortality rates from 0.19 to 0.40 every 10,000 inhabitants.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">3</span></a> Outbreaks mainly take place in health care centres, schools, restaurants, cruises long-term health care centres, and daytime centres.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">2</span></a> Only in the U.S.A., the estimated incidence of this disease in cruises is 25.6 every 10,000 inhabitants, constituting the main cause of gastroenteritis.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">4</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">This disease is more frequently seen in developing countries as a result of poor sanitary and hygienic conditions, although there are discrepancies in terms of rates, probably due to the difficulties in reaching a diagnosis, given the concomitance of other gastrointestinal diseases, both bacterial and parasitic.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">At-risk population: the incidence rate of this disease is very high among children under 5 years of age (2140 every 10,000 inhabitants); this virus is responsible for 18% of diarrhoea processes,<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">3</span></a> and constitutes the second cause of endemic diarrhoea within this population after rotavirus.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">5</span></a> Population at risk also includes people over 65 years of age and immunosuppressed patients.<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">3,6</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Among humans, the virus has a person-to-person transmission (faecal-oral and vomit-oral) or, indirectly, through the consumption of foods and water or through environmental transmission. Zoonotic transmission is unusual, since this virus is highly selective in terms of its hosts. Person-to-person transmission is responsible for 90% of <span class="elsevierStyleItalic">Norovirus</span> outbreaks in health care centres. In order for food and water consumption and environmental transmission to be viable, the food, water or fomite in question must have been previously contaminated with viral particles from an infected human.<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">7</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">In Europe and the U.S.A., an approximate 10% and 26%, respectively, of <span class="elsevierStyleItalic">Norovirus</span> outbreaks are estimated to be caused by food transmission,<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">3</span></a> with low hospitalisation and mortality rates (1% and 0.01%, respectively),<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">1</span></a> the main source of food poisoning being the hands of the subject handling food,<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">7</span></a> followed by raw vegetables and molluscs consumption.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">1</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Norovirus</span> was discovered in 1972, while studying a gastroenteritis outbreak in an elementary school located in Norwalk (Ohio, U.S.A.) by Kapikian et al.<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">8</span></a> It belongs to the <span class="elsevierStyleItalic">Caliciviridae</span> family, which includes five other types of viruses: <span class="elsevierStyleItalic">Sapovirus</span>, <span class="elsevierStyleItalic">Lagovirus</span>, <span class="elsevierStyleItalic">Vesivirus</span>, <span class="elsevierStyleItalic">Becovirus</span> and <span class="elsevierStyleItalic">Recovirus.</span> It is small (27–40<span class="elsevierStyleHsp" style=""></span>nm), unwrapped and icosahedral virus. Its genome consists of a simple RNA molecule with a 7.5<span class="elsevierStyleHsp" style=""></span>kb positive polarity, and to date, it has not been possible to isolate or cultivate human <span class="elsevierStyleItalic">Norovirus</span> in cellular cultures.<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">6</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Within the <span class="elsevierStyleItalic">Norovirus</span> type of virus, there are six gene groups<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">1</span></a>: GI, GII and GIV are mostly isolated in humans, whereas GIII, GV and GVI are isolated in animals. These gene groups are, in turn, divided into more than 38 genotypes based on the amino acid sequence variation for capsid protein VP1, and those with a variation below 15% belong to the same genotype.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">1</span></a><span class="elsevierStyleSup">,</span><a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">9</span></a> Typically, there is a considerable number of different genotypes co-circulating, and they vary significantly year after year<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">10</span></a>; however, due to unknown reasons, a unique and predominant viral strain has appeared, spreading widely and causing most cases. Since 2002, the gene group GII and variants of genotype GII.4 within this group are responsible for most gastroenteritis outbreaks, including pandemics and sporadic cases.<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">1,9</span></a> However, this does not always take place, as seen in the study by Manso et al.,<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">11</span></a> who noted a higher prevalence of gene group GI over II, and the increase of unusual genotypes such as GII.14. During the last decade, new variants of genotype II.4 (thus classified for having differences >5% in the protein VP1 amino acid sequence)<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">11</span></a> have appeared every 2–3 years, replacing viral strains that had prevailed before.<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">12,13</span></a> A clear example is the global replacement of variant GII.4 New Orleans 2009 for variant GII.4 Sydney 2012.<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">10,14</span></a> It is believed that genotype II.4 might suffer a sequential evolution process similar to that suffered by flu viruses.<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">6</span></a> Finally, there is an association between genotypes and types of transmission: GI is associated with water or food consumption, but G4.<span class="elsevierStyleSmallCaps">II</span> is associated with person-to-person transmission at health care centres.<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">7</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Norovirus</span> is considered a highly infectious virus for a number of reasons: the infectious dose is very low (approximately 10 viral particles)<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">6</span></a> and high viral loads are detected in faeces (1<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">10</span> copies of RNA/g). Virus excretion may take place in asymptomatic carriers, in symptomatic carriers before and after clinical manifestation, it may persist up to 2 weeks after symptoms disappeared,<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">9</span></a> diarrhoea may even persist and the virus may even continue to spread during months in transplanted patient.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">3</span></a> It is a very stable virus under adverse environmental conditions. Due to the fact that its infectious capacity remains in temperatures of −60<span class="elsevierStyleHsp" style=""></span>°C, acid pH, they are relatively resistant to disinfectants such as ethanol and chlorine, and they can survive 2 weeks on surfaces.<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">1,6,7</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Even though infections take place throughout the year, in temperate climate areas they seem to have a higher incidence during wintertime. However, outbreaks may present different seasonal patterns: in summertime, they are mostly seen in cruises, while in wintertime, they are mostly seen in health care centres.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">2</span></a> Besides, there are certain seasonal variations according to the gene group of the responsible virus.<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">14</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">The gastroenteritis caused by these viruses appears suddenly after a 24<span class="elsevierStyleHsp" style=""></span>h incubation period (limits 12–72<span class="elsevierStyleHsp" style=""></span>h). In general, the clinical condition lasts from 12 to 60<span class="elsevierStyleHsp" style=""></span>h, and it is characterised by self-limiting diarrhoea, nausea, vomiting and abdominal pain, being vomiting and diarrhoea the more prevalent symptoms among children and adults, respectively, and with cases of vomiting where there is no diarrhoea.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">3</span></a> Nevertheless, not every infected patient develops the disease<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">6</span></a>; in fact, <span class="elsevierStyleItalic">Norovirus</span> is frequently detected in the faeces of healthy subjects.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">3</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Infection susceptibility has been associated to the presence of H blood group hydrocarbonated antigens, which also express in gastrointestinal epithelial cells, acting as receptors of the virus in the intestine. Therefore, the absence of secretion of these antigens is associated with the resistance to infection by <span class="elsevierStyleItalic">Norovirus</span>.<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">6</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">It is possible to develop immunity to certain genotypes, with an estimated duration of 4–8 years. However, the large variety and the emergence of new viral strains may trigger successive infections during a lifetime.<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">15</span></a> Children are more prone to get infected than adults, due to their lower hygiene level and their higher social contact.<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">15</span></a> Moreover, unlike adults, children tend to get infected by several genotypes at once.<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">11</span></a> All of these elements turn said population into a very important link in the transmission chain, along with health care workers, and thus, developing a vaccine against this virus would be very beneficial, both directly and indirectly.</p><p id="par0065" class="elsevierStylePara elsevierViewall">The laboratory diagnosis may be obtained by means of enzyme-linked immunomethods and/or molecular biology techniques. The former have an elevated specificity, of approximately 100%, and do not present cross reactions with other viruses. However, their sensibility is estimated in 50–80% and varies according to the gene groups causing the disease. Furthermore, the storage conditions of these samples may affect the sensibility of these techniques, improving them when samples are subject to a freezing/unfreezing process, due to the subsequent elimination of inhibitors.<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">16</span></a> Finally, the molecular biology technique from the chain reaction of the reverse transcriptase polymerase is the reference procedure for the diagnosis of infections by <span class="elsevierStyleItalic">Norovirus</span>.<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">17</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Norovirus</span> asks for a special mention in health care centres, and, specifically, in long-term stay health care centres. Although the elderly population within the community is not at high risk of contracting this infection, the situation is different for those staying at these health care centres, where the infection rate amounts to approximately 55%, and the mortality rate is elevated<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">3</span></a> (estimated in 6 every 10,000 inhabitants). This is due to the high person-to-person viral transmission, but cases are isolated both in symptomatic and asymptomatic patients and health care workers, as shown by the study conducted by Moreno et al.<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">18</span></a> published in this edition, since comorbidities, cognitive deficits and digestive disorders affecting this population make it difficult to identify cases, it is necessary to amplify studies within these populations to quickly identify cases and intervene accordingly in order to control the infection.<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">19</span></a></p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:2 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Hernández Porto M, Lecuona M. <span class="elsevierStyleItalic">Norovirus</span> y su creciente importancia clínica. Med Clin (Barc). 2015;144:207–208.</p>" ] 1 => array:2 [ "etiqueta" => "☆☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">See related content at doi: <span class="elsevierStyleInterRef" id="intr0005" href="doi:10.1016/j.medcle.2015.05.042">http://dx.doi.org/10.1016/j.medcle.2015.05.042</span></p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:19 [ 0 => array:3 [ "identificador" => "bib0100" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Vital signs: foodborne norovirus outbreaks – United States, 2009–2012" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "A.J. Hall" 1 => "M.E. Wikswo" 2 => "K. Pringle" 3 => "L.H. Gould" 4 => "U.D. 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Journal Information
Vol. 144. Issue 5.
Pages 207-208 (March 2015)
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Vol. 144. Issue 5.
Pages 207-208 (March 2015)
Editorial article
Norovirus and its increasing clinical importance
Norovirus y su creciente importancia clínica
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Miriam Hernández Porto
, María Lecuona
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Servicio de Microbiología y Medicina Preventiva, Hospital Universitario de Canarias, La Laguna, Tenerife, Spain
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