Brief report
Norovirus outbreaks in geriatric centres: Importance of an early detection
Brotes de infección por norovirus en centros geriátricos: importancia de una detección precoz
Antonio Morenoa,b,
, Sandra Manzanares-Layaa, Efren Razquinc, Susana Guixd, Ángela Domínguezb,e, Mercedes de Simónc, Working Group for the Study of Acute Viral Gastroenteritis Outbreaks in Catalonia ◊
Corresponding author
a Agencia de Salud Pública de Barcelona (ASPB), Barcelona, Spain
b CIBER Epidemiología y Salud Pública CIBERESP, Spain
c Laboratorio de la ASPB, Barcelona, Spain
d Grupo de virus entéricos, Departamento de Microbiología, Universidad de Barcelona, Barcelona, Spain
e Departamento de Salud Pública, Universidad de Barcelona, Barcelona, Spain
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Barcelona, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Grupo de virus entéricos, Departamento de Microbiología, Universidad de Barcelona, Barcelona, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "Departamento de Salud Pública, Universidad de Barcelona, Barcelona, Spain" "etiqueta" => "e" "identificador" => "aff0025" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Brotes de infección por norovirus en centros geriátricos: importancia de una detección precoz" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Recent socio-economic changes, combined with a caseload increase, have encouraged the emergence of institutions where elderly population is admitted, favouring acute gastroenteritis (AGE) outbreaks with a viral aetiology, mainly caused by norovirus (NV).<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1,2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The multiple mechanisms of NV transmission, its adaptability, its resilience to standard disinfectants and its infective capacity turn AGE caused by NV into relevant processes, especially in closed institutions with vulnerable populations.<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">3–5</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Currently, there are polymerase chain reaction (PCR) techniques that make it possible to identify causative agents of NV outbreaks. Over the last decade, the NV GII.4 genotype has been responsible for most of these outbreaks worldwide.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The purpose of this study was to know the incidence of NV outbreaks in nursing homes, the mechanisms for its transmission and the genotype involved.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Patients and methods</span><p id="par0025" class="elsevierStylePara elsevierViewall">Descriptive study of outbreaks presenting clinical characteristics compatible with viral AGE aetiology identified in nursing homes located in the city of Barcelona, between January 1, 2010, and December 31, 2012, and duly notified to the <span class="elsevierStyleItalic">Agència de Salut Pública de Barcelona</span> (Public Health Agency of Barcelona, ASPB).</p><p id="par0030" class="elsevierStylePara elsevierViewall">Data pertaining to the cases and episodes documented in this study were collected from epidemiological surveys by the Epidemiology Department of the ASPB. Whenever the information could not be obtained directly from nursing home residents, it was obtained through nursing homes staff. The minimum follow-up for each outbreak was 6 days after the last episode onset. Due to the absence of samples to be analyzed, clinical and epidemiological criteria were followed.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> The clinical severity, the onset date and the symptoms duration, as well as the incidence rates among nursing home residents and staff, were all assessed.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Faeces samples from residents affected by this condition as well as from personnel were taken and submitted to the ASPB laboratory for NV detection through PCR reverse transcription (RT-PCR). Nucleic acid was extracted from microorganisms by means of lysis and magnetic purification. The detection of the NV genome from the extracted samples was made using the Immundiagnostik MutaRex NV kit, and the detection of the NV gene groups I and II was made by means of another RT-PCR in real time. The genotyping of NV strains was carried out in the Enteric Virus Laboratory from the Department of Microbiology, at the University of Barcelona, by sequencing a fragment obtained by means of <span class="elsevierStyleItalic">semi-nested</span> RT-PCR reactions specific for those gene groups. The fragment sequence analysis from 330 to 334 basis pairs obtained provides genotypic information from the samples.<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">7,8</span></a> Samples from nursing home staff whose NV was isolated were taken until clearance of virus was obtained.</p><p id="par0040" class="elsevierStylePara elsevierViewall">In the food transmission outbreak, the reference menu, presumably involved in the food transmission outbreak, was assessed in order to determine the compatible aetiological agent. Research of NV in outbreak number 5 was not viable since samples could not be collected as a result of an outbreak announcement delay.</p><p id="par0045" class="elsevierStylePara elsevierViewall">For statistical purposes, the incidence rates and the duration of person-to-person transmission outbreaks were compared to those of common-source outbreaks, by means of the <span class="elsevierStyleItalic">Z</span>-test for proportions comparison and the <span class="elsevierStyleItalic">T</span>-test for independent samples, respectively. Statistical packages PASW18 and EPIDAT3.1 were used.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0050" class="elsevierStylePara elsevierViewall">A total of 27 outbreaks with aetiology suggestive of NV were reported; 5 of them (18.5%) took place in nursing homes, and they were included in the analysis. The presence of NV was confirmed in 4 outbreaks, and in the fifth one, it was attributed to NV, following clinical–epidemiological criteria.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> Two outbreaks were identified in March 2011 and 3 more were detected in September, October and November 2012, respectively (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">There were 95 cases detected among nursing home residents, with an average of 82.2 years of age. In 3 outbreaks, 80% were females, and in one, 77.3% were males.</p><p id="par0060" class="elsevierStylePara elsevierViewall">The average lapse between the onset of the first case and its announcement was 8 days for interpersonal transmission outbreaks, and one for food-borne outbreaks. Due to the epidemic curve, transmission in 4 of the outbreaks was considered to have been interpersonal. The fifth case was associated with food-borne exposure, and the few secondary cases were identified as interpersonal transmission.</p><p id="par0065" class="elsevierStylePara elsevierViewall">Symptoms were mild in all cases except for that of an 84-year-old male who was admitted at a hospital centre and passed away as a result of bronchoaspiration (lethality of 1.05%). The average duration per episode ranged from 1 to 2 days.</p><p id="par0070" class="elsevierStylePara elsevierViewall">The incidence rate was 40.6%, whereas it varied significantly among nursing home staff. In food-borne outbreaks, the rate (28.8%) was significantly lower than the one in interpersonal transmission outbreaks (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.05), which oscillated between 46.2% and 55.7%.</p><p id="par0075" class="elsevierStylePara elsevierViewall">In those outbreaks where the number of episodes was identified, the incidence rate oscillated between 42.9% and 53.3%.</p><p id="par0080" class="elsevierStylePara elsevierViewall">The average duration of food-borne transmission outbreaks was significantly lower (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.01) than the one in interpersonal transmission outbreaks (4 and 8.7 days, respectively). The duration of outbreak number 5 could not be established since the outbreak announcement was delayed.</p><p id="par0085" class="elsevierStylePara elsevierViewall">In 3 interpersonal transmission outbreaks, NV was detected in the faeces of asymptomatic nursing home personnel and personnel with GEA. No samples could be collected from the fourth outbreak. NV was not detected in the faeces of nursing home staff under study, all of whom were asymptomatic, in the food-borne outbreak.</p><p id="par0090" class="elsevierStylePara elsevierViewall">In each of the outbreaks where faecal samples were obtained, NV was detected in at least 4 or more samples. The molecular study identified NV GII.4 genotype in 75% of outbreaks. No bacterial enteropathogens were detected in food items involved in the food-borne outbreak.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0095" class="elsevierStylePara elsevierViewall">A total of 5 NV epidemic outbreaks that occurred in nursing homes were studied, and molecular epidemiology techniques could be applied in 4 of them. In 4 of the interpersonal transmission outbreaks, both the incidence rate among nursing home residents and the outbreak duration were higher than those observed in food-borne outbreaks. High incidence rates are indicative of high infection transmission levels within these institutions, as noted by other authors.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1,2</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">It is known that food-borne outbreaks have higher incidence rates within the community than within health care centres, which could be related to the detection speed in closed areas. The highest incidence rates described in our study were detected among interpersonal transmission outbreaks, which might be due to a delay in the identification of cases and in its ensuing notification. Typically mild symptomatology, comorbidity, cognitive deficiency and digestive disorders among residents might contribute to making initial cases pass unnoticed.</p><p id="par0105" class="elsevierStylePara elsevierViewall">NV AGEs, even when they are mild, might pose an additional risk for vulnerable populations. An elderly male who was a subject in our study was admitted at a hospital and passed away as a result of bronchoaspiration, which entailed a lethality similar to the one described in medical literature.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">The number of episodes exceeded the number of cases, which could be attributed to the absence of immunity caused by the NV, its low infectious dose and its high contagious nature. The nursing home with the highest difference ratio between incidence rate episodes and cases had the longest active outbreak, which could evidence a deficient outbreak management.</p><p id="par0115" class="elsevierStylePara elsevierViewall">The most frequently identified genotype was GII.4 (75%), indicating that the viral strain circulation in nursing homes is similar to the one we detected in the community.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">Due to the lack of standardized procedures, the presence of NV could not be established in food items involved in the food-borne outbreak, and the role played by high-risk surfaces in the transmission could not be established either. Besides, the delay in outbreaks notification made it difficult to conduct an appropriate investigation in some of the outbreaks. In spite of these limitations, our study aims at highlighting the importance of early detection and notification for the correct management of these outbreaks. The recommendation is to establish adequate alarm systems in this area, to reinforce control measures and to impinge upon surface control and asymptomatic carriers detection, which could all contribute to minimizing NV outbreaks.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Funding</span><p id="par0125" class="elsevierStylePara elsevierViewall">This study has been funded by the <span class="elsevierStyleGrantSponsor" id="gs1">Instituto de Salud Carlos III</span> (Project PS09/02516) and <span class="elsevierStyleGrantSponsor" id="gs2">AGAUR</span> (Project 2009/SGR 42).</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conflicts of interest</span><p id="par0130" class="elsevierStylePara elsevierViewall">The authors declare that there are no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres577878" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Background and objectives" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Patients and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec594568" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres577879" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Fundamento y objetivos" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Pacientes y método" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec594567" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Patients and methods" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Funding" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Conflicts of interest" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2014-02-25" "fechaAceptado" => "2014-05-22" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec594568" "palabras" => array:4 [ 0 => "Outbreaks" 1 => "Norovirus" 2 => "Nursing homes" 3 => "Gastroenteritis" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec594567" "palabras" => array:4 [ 0 => "Brotes" 1 => "Norovirus" 2 => "Geriátricos" 3 => "Gastroenteritis" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Background and objectives</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Acute gastroenteritis (AGE) outbreaks of norovirus (NV) occur frequently in nursing homes. Gastrointestinal disorders and degree of dependence of residents complicate early detection and implementation of control measures. Our study's aim was to determine the incidence of NV in elderly care centres, transmission mechanisms and circulating genotypes.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Patients and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">An epidemiological study of NV outbreaks reported to the Public Health Agency of Barcelona 2010–2012 was performed. The attack rate, outbreak duration, symptomatology and identified NV genotypes were analyzed.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">In total, 27 NV outbreaks were reported and 5 (18.5%) occurred in nursing homes (95 cases with lethality of 1.05%). The aetiology of one of the five outbreaks could not be confirmed because of late notification. Four of the outbreaks were attributed to person-to-person transmission. The outbreak duration and attack rate among resident person-to-person transmission were significantly higher compared to common exposure transmission. Genotype GII.4 was predominant.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The identification of critical points and the use of clinical alarm systems could prevent and minimize the spreading and severity of these outbreaks.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Background and objectives" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Patients and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Fundamento y objetivos</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Los brotes de gastroenteritis aguda (GEA) por norovirus (NV) son frecuentes en geriátricos. Los trastornos gastrointestinales previos y el grado de dependencia de los residentes dificultan la detección y la implementación de medidas de control. El objetivo de nuestro estudio fue conocer la incidencia de los brotes por NV en geriátricos, las vías de transmisión y los genotipos causales.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Pacientes y método</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Estudio epidemiológico de los brotes por NV notificados en Barcelona durante 2010-2012. Se analizaron las tasas de ataque, la duración de los brotes, la sintomatología de los episodios y los genotipos circulantes.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Se notificaron 27 brotes por NV; 5 (18,5%) en geriátricos, que afectaron a 95 personas, con una letalidad del 1,05%. El retraso en la notificación dificultó la investigación en uno de los brotes. La transmisión fue interpersonal en 4 brotes, cuya duración y tasas de ataque entre los residentes fueron mayores que en el brote de exposición común. El genotipo predominante fue el GII.4.</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Es necesario identificar los puntos críticos en los centros y establecer sistemas de alarma para prevenir y minimizar la extensión y la severidad de estos brotes.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Fundamento y objetivos" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Pacientes y método" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:2 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Please cite this article as: Moreno A, Manzanares-Laya S, Razquin E, Guix S, Domínguez Á, de Simón M, et al. Brotes de infección por norovirus en centros geriátricos: importancia de una detección precoz. Med Clin (Barc). 2015;144:204–206.</p>" ] 1 => array:3 [ "etiqueta" => "◊" "nota" => "<p class="elsevierStyleNotepara" id="npar0015">Members of the Working Group for the Study of Acute Viral Gastroenteritis Outbreaks in Catalonia appear in the <a class="elsevierStyleCrossRef" href="#sec0035">Appendix A</a>.</p>" "identificador" => "fn0005" ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:4 [ "apendice" => "<p id="par0135" class="elsevierStylePara elsevierViewall">Other members of this working group are:</p> <p id="par0140" class="elsevierStylePara elsevierViewall">M. Alsedà, J. Álvarez, C. Arias, A. Artigues, I. Barrabeig, P.J. Balañà, N. Camps, M. Company, M. Carol, G. Ferrús, N. Follia, P. Godoy, A. Martínez, I. Parrón, A. Rovira, M.R. Sala, N. Torner, R. Torra, J. Torres (Public Health Agency of Catalonia [Agencia de Salud Pública de Cataluña])</p> <p id="par0145" class="elsevierStylePara elsevierViewall">S. Broner (Consortium for Biomedical Research in Epidemiology & Public Health [CIBER Epidemiología y Salud Pública]).</p> <p id="par0150" class="elsevierStylePara elsevierViewall">J.A. Caylà, S. Lafuente, M. Sanz (Agència de Salut Pública de Barcelona).</p> <p id="par0155" class="elsevierStylePara elsevierViewall">D. Ferrer (Laboratory of the Agència de Salut Pública de Barcelona).</p> <p id="par0160" class="elsevierStylePara elsevierViewall">R. Bartolomé, T. Cornejo (Microbiology Laboratory of the Hospital Vall d’Hebron).</p> <p id="par0165" class="elsevierStylePara elsevierViewall">A. Bosch, R.M. Pintó (Enteric Virus Group at the University of Barcelona).</p>" "etiqueta" => "Appendix A" "titulo" => "Working Group Conducting the Study on Acute Viral Gastroenteritis Outbreak in Catalonia" "identificador" => "sec0035" ] ] ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:3 [ "leyenda" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">NA, not available.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Outbreak announcement code and date \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Duration (days) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Study population \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Total number of cases (incidence rate) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Total number of episodes \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Total number of cases among residents (incidence rate) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Total number of cases among personnel (incidence rate) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Mechanism of transmission \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Norovirus genotype \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Outbreak 1, March 2011 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">56 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">19 (33.9%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">24 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">17 (55.0%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2 (8.0%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Interpersonal \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">GII.4 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Outbreak 2, March 2011 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">50 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">21 (42.0%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">23 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">13 (44.8%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">8 (38.0%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Interpersonal \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">GII.4 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Outbreak 3, September 2012 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">111 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">58 (52.3%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">59 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">44 (55.7%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">14 (43.7%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Interpersonal \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">GII.6 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Outbreak 4, October 2012 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">52 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15 (28.8%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15 (28.8%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Food-borne \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">GII.4 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Outbreak 5, November 2012<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">13 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 (46.2%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 (46.2%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Interpersonal (probable) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NA \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab943104.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Outbreak microbiologically not confirmed. Announced 13 days after the last case.</p>" ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Characteristics of norovirus outbreaks in nursing homes. Barcelona, 2010–2012.</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" => "Epidemiology of multidrug-resistant microorganisms among nursing homes residents in Belgium" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "B. Jans" 1 => "D. Schoevaerdts" 2 => "T.D. Huang" 3 => "C. Berhin" 4 => "K. Latour" 5 => "P. Bogaerts" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1371/journal.pone.0064908" "Revista" => array:5 [ "tituloSerie" => "PLOS ONE" "fecha" => "2013" "volumen" => "8" "paginaInicial" => "e64908" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23738011" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0060" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Brotes de gastroenteritis aguda vírica en residencias de ancianos, sistema de detección por umbral de prevalencia (SIDUP)" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "J.B. Bellido-Blasco" 1 => "C. Rubert-Escrig" 2 => "M. Salvador-Ribera" 3 => "E. Silvestre-Silvestre" 4 => "M.D. Tirado-Salvador" 5 => "S. Sabater-Vidal" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Rev Esp Salud Pública" "fecha" => "2009" "volumen" => "83" "paginaInicial" => "669" "paginaFinal" => "678" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20111815" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0065" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Chronic shedders as reservoir for nosocomial transmission of norovirus" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "F.H.A. Sukhrie" 1 => "J.J. Siebenga" 2 => "M.F.C. Beersma" 3 => "M. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2017 October | 6 | 3 | 9 |
| 2017 September | 8 | 2 | 10 |
| 2017 August | 14 | 3 | 17 |
| 2017 July | 4 | 1 | 5 |
| 2017 June | 5 | 3 | 8 |
| 2017 May | 6 | 3 | 9 |
| 2017 April | 8 | 2 | 10 |
| 2017 March | 10 | 2 | 12 |
| 2017 February | 1 | 0 | 1 |
| 2015 November | 1 | 0 | 1 |
