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노로바이러스감염관리
가톨릭관동의대이혁민
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Cause of acute gastroenteritis• Virus : most common
‒ Norovirus, rotavirus, adenovirus, astrovirus
‒ Sapovirus, coronavirus, torovirus, picobirnavirus, Aichi virus, etc
• Bacteria
‒ Salmonella, Shigella, campylobacter
‒ EHEC, ETEC
‒ S.aureus
‒ C. difficile: Healthcare-associated
• Parasite, protozoa
‒ Giardia, Entamoeba
‒ Cryptosporidium
• Non-infectious causes: toxins, food allergy, heavy metals, antibiotics, etc
• Unknown : ~50%
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Positive specimens
(N)
Total specimens(N)
Isolated rate(%)
Bacteria 5종 54 1,871* 2.9%
Viruses 5종 776 1,871 41.5%
Total 830 1,871 44.4%
(질병관리본부, 2008.4-2010.3, n=1,871)
Etiologic agent of gastroenteritis(Korea, 2008.4-2010.3)
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The distribution of bacteria
(질병관리본부, 2008.4-2010.3, n=1,871)
Salmonella spp.
61.1%
Campylobacter spp.
25.9%
ETEC9.3%
EHEC1.9% Shigella spp.
1.9%
Salmonella spp.
Campylobacter spp.
ETEC
EHEC
Shigella spp.
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Salmonella and Shigella spp.
Short survival period: 1 day – 4 weeksHigh infective dose: 105 CFU
Salmonella spp.
Shigella spp.
Moderate survival period: 2 days – 5 months High infective dose: 180 CFU
Kramer A. et al, BMC Infect Dis 2006; DAVID L. S., Clin Microbiol Rev 1995
Patient infection control
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The distribution of viruses
(질병관리본부, 2008.4-2010.3, n=1,871)
Rotavirus42.8%
Norovirus43.0%
Adenovirus11.4%
Astrovirus2.3%
Sapovirus0.4%
Rotavirus
Norovirus
Adenovirus
Astrovirus
Sapovirus
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Norovirus
• Non-enveloped single-stranded RNA virus
• Epidemiology
– 18% of all cases of acute gastroenteritis worldwide
– 90% of epidemic nonbacterial outbreaks of gastroenteritis
– 50% of all foodborne outbreaks of gastroenteritis in the US
– 267 million infections per year
– Over 200,000 deaths per year: Infants and elderly
• Five genogroups
– GI and GII: The most prevalent genogroups in human infection
– GIII: Bovine infection
– GV: Mice infection
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Clinical manifestations of norovirus
• General characteristics
– Incubation period: 12-48 hrs
– Symptoms: Nausea, forceful vomiting, watery diarrhea
abdominal pain, mild fever, body ache (Stomach flu)
– Self-limiting in a few days
– Sometimes severe infection in infant and elderly patients
• Incomplete and temporary immunity to norovirus
– Complete loss of immunity in 8 weeks to 6 months
– Recurrent infection of same strains or heterologous strains
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Table Transmission and epidemiology of the major gastroenteritis viruses
Virus Mode of transmission Target population Occurrence
RotavirusFecal-oral, ?respiratory,
?food and waterChildren <5 yrs old (peak activity at 6 mo to 2 yr)
Fall/winter months in temperate climates, year round in tropical regions
NorovirusFecal-oral, foods, water,
?respiratoryAll age groups
Winter peak, year-round outbreaks common in variety
of settings
Sapovirus Fecal-oral, ?respiratoryMainly children (primarily
infants and toddlers), less so in adults
Sporadic year round, outbreaks occur
Enteric Adenovirus Fecal-oral, ?respiratoryMainly infants and young
children < 5 yrs oldSporadic year round,
outbreaks occur
AstrovirusFecal-oral, water,
?respiratory Mainly young childrenSporadic year round,
outbreaks occur
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Table Selected clinical features of the major gastroenteritis viruses
Virus Clinical significanceIncubation
(days)Vomiting
(days)Diarrhea
(days)
Virus shedding
(days)
RotavirusAcute severe dehydrating gastroenteritis, hospital-acquired infections (HAI), subclinical infections occur
1-2 2-3 5-8 8-10
Caliciviruses
Noroviruses: moderate to severe AGE, HAI, prolonged shedding and chronic disease in immunocompromised patients, subclinical infections occur
Sapoviruses: mild to moderate gastroenteritis, subclinical infections occur
1-2 0.5-1 1-2 1-21
Enteric Adenovirus
Moderate to severe gastroenteritis, HAI, persists in immunocompromised patients
8-10 2-3 4-12 8-13
AstrovirusMild to moderate gastroenteritis, subclinical infections
occur1-2 1-4 1-4 8-10
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Pandemic outbreak of norovirus
• Influenza 와비슷한역학: 2-3년마다새로운 GII.4 variants가나타나서epidemic을일으킴• Pandemics : 3개이상의대륙• US 1995/96 in late 1990s• Farminton Hills virus in 2002• Hunter virus in 2004• Den Haag 2006b virus in 2007-2008• New Orleans virus 2009 in 2009-2012• GII.4 Sydney 2012
• Localized epidemics in specific region, but not global• Japan 2001, Henry 2001, Asia 2003, Yerseke 2006a, Osaka 2007,
Apeldoorn 2008
Pandemics of influenza A virus
• 1918 Spanish flu H1N1
• 1957 Asian flu H2N2
• 1968 Hong Kong flu H3N2
• 2009 novel flu H1N1 (Mexico)
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Korean Food and Drug Administrationhttp://www.mfds.go.kr/fm/index.do?nMenuCode=79
Healthcare Bigdata Hub
1667
20172107
2814
1726
0
500
1000
1500
2000
2500
3000
2011 2012 2013 2014 2015
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Special characteristics of norovirus in infection control
• Highly contagious virus (Infective dose < 10)– Ingestion of contaminated food or water– Direct contact with infected person: 109-12 particle/1g of feces– Surface or food contamination by direct contact or aerosolization
(100 million particle/1g of dried vomitus)
• Viral shedding: from before symptom onset to 2 weeks
– 30% of patients Asymptomatic
• Stable in environment
– Hard surface: several weeks
– Fabric surface: 12 days
– Water: Several months - years
• Stable to some kinds of antiseptics
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J Infect Dis 2014
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Blaney DD, et al. Am J Infect Control 2012Steinmann J, et al. Antimicrob Resist Infect Control 2013
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Zheng DP, et al. J Clin Microbiol 2010
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Hall AJ, et al. MMWR 2014
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Barclay L, et al. Clin Microbiol Infect 2014
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Infection control of Norovirus
Infection control measures suggested
• Contact precautions
– Patient isolation and cohorting
– A minimum of 48 hours after resolution of symptoms
• Enhanced hand hygiene
– Wash with soap and water for 20 seconds
– Alcohol-based hand sanitizers: Ineffective (Non-enveloped virus)
• Environmental infection control measures
– Chemical cleansing (Chlorine-based disinfectant)
• Exclusion of ill staff from work for a minimum of 48 hours after symptom resolution
• Surveillance for new and resolving cases
http://www.cdc.gov/hai/pdfs/norovirus/NoroVirus-Gen508.pdf
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Patient isolation/Cohorting
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Hand hygiene
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환자이송및병동폐쇄
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의료기관조리사및배식원
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진단
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개인보호장구
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환경소독
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직원관리
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방문객관리
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교육
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능동적감시 (Active case-finding)
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소통및고지
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Kaplan criteria
• Vomiting in more than half of symptomatic cases
증상이있는환자의절반이상이구토
• Mean (or median) incubation period of 24 to 48 hours
평균또는중간잠복기 24-48시간
• Mean (or median) duration of illness of 12 to 60 hours
이환기간 12-60시간
• No bacterial pathogen isolated in stool culture
변배양에서장염세균음성
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Diagnostic method
Kaplan criteria EIA/ELISA EM NASBA
Sensitivity 68 31-90 24-58 100
Specificity 99 65-100 98-99 50
PPV 97 52-100 88-94 -
NPV 82 56-97 - -
• Reference method: PCR
![Page 47: Emerging and Re-emerging infectious diseases in Korea · 2015. 12. 18. · The distribution of viruses. (질병관리본부, 2008.4-2010.3, n=1,871) Rotavirus 42.8% Norovirus 43.0%](https://reader036.vdocuments.us/reader036/viewer/2022071419/6117c4af3d1d84309d65c81e/html5/thumbnails/47.jpg)
결론
• 노로바이러스국내감염흔함
• 노로바이러스는주요의료관련감염원인
• 비누를사용한손씻기시행
• 격리또는코호트운영 (증상소실후 48시간까지)
• 환경관리
• 적절한진단법사용 (Kaplan method)