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Norwalk-like viral gastroenteritis outbreak in U.S. Army trainees.

An outbreak of acute gastroenteritis hospitalized 99 (12%) of 835 U.S. Army trainees at Fort Bliss, El Paso, Texas, rom August 27 to September 1, 1998. Reverse transcriptase polymerase chain reaction tests for Norwalk-like virus were positive for genogroup 2. Gastroenteritis was associated with one post dining facility and with soft drinks.

Norwalk viral gastroenteritis has been identified as an important cause of illness among military troops (1-3). We report the epidemiologic, environmental, and laboratory investigations of a large foodborne outbreak of acute gastroenteritis in military trainees in which a Norwalk-like virus, genogroup 2 (NLV2), was identified by reverse transcriptase-polymerase chain reaction (RT-PCR).

The Outbreak

From August 27 to September 1, 1998, 99 soldiers with acute gastroenteritis, assigned to the Fort Bliss Air Defense Artillery Training site, El Paso, Texas, were admitted to the William Beaumont Army Medical Center for observation and hydration. The criteria for admission were lack of medical care in barracks and isolation of cases to contain the outbreak. All soldiers admitted to the medical center with gastroenteritis were isolated in a temporary medical facility. The most prominent symptoms were acute nausea, vomiting, abdominal pain, diarrhea, and fever (Table 1). The median hospital stay was 24 hours (12 to 72 hours). Initial clinical laboratory evaluations suggested acute viral gastroenteritis (Table 2). All soldiers were from the same unit and lived near each other in the training area compound, a rectangular block of 15 buildings. The hospitalization rate for gastroenteritis in this unit for the week of August 27 was 99 (12%) of 835. The compound had two dining facilities, DF1 and DF2, located across from each other in the center of the compound. Preliminary interviews with hospitalized patients implicated DF1, which was closed on August 28. Although some patients preferred one dining facility over the other, in general they dined as directed by their drill sergeants or where the wait was shortest. In addition to U.S. soldiers, the unit trained small numbers of US marines and Japanese defense force personnel, who also used these dining facilities.
Table 1. Frequency of symptoms in hospitalized soldiers

Symptom No.(a) %

Nausea 79/90 88
Vomiting 72/90 80
Abdominal pain 68/90 76
Diarrhea 60/90 67
Fever/chills 37/90 41
Headache 20/90 22
Photophobia/eye pain 3/90 3


90 records were abstracted from 99 hospitalized soldiers
Table 2. Frequency of selected findings in hospitalized soldiers

Sign/finding No. %

Tmax > 99.5 [degrees] F 28 / 90 38
Tmax > 100.4 [degrees] F 17 / 90 19
WBC > 10,600 10 / 60(a) 17
Platelets < 150,000 22 / 60(a) 37


(a) Sixty of 90 abstracted records reported white blood cells and platelet counts.

Tmax, maximum temperature.

WBC, white blood cells.

Patients, food handlers, facility engineers, post public health officers, and training unit officers were interviewed, and the training compound and dining facilities were inspected. Sign-in rosters, menus, and meal preparation documents, as well as daily personnel status reports and training schedules, were reviewed. Cases were mapped by building of residence. Foodborne outbreak questionnaires were administered to 86 of the hospitalized patients available for interview; a randomly chosen (using the last digit of Social Security numbers: 3,5,7) group of 198 soldiers who had not sought medical care; and US marines and 15 Japanese defense force troops (total 323 questionnaires).

Because of the time elapsed since the start of the outbreak, the questionnaire was designed with a food preference format, based on the foods listed on the previous week's menu. Data were abstracted from 90 inpatient records and 323 questionnaires and meal sign-in rosters from August 25 to August 27, 1998, and were analyzed for trends by SPSS, a statistical software package. The case definition for acute gastroenteritis was three or more loose diarrheal stools (with or without vomiting) within a 24-hour period in the week before the outbreak, with or without admission to the hospital. To better characterize the point source of the outbreak, 98 (77.8%) of 126 cases with onset on August 27 to August 28 were termed "first wave" cases and were compared with propagated cases and controls for association with selected exposures (Table 3).
Table 3. Odds ratios (OR) for selected foods and dining facilities

 Univariate Univariate
Exposure analysis OR 95% CI

Ever ate at DF1 in week prior(a) 9.8 (2.8, 40.2)
Ate in DF1 preferentially(b) 3.7 (2.0, 6.9)
Ever ate at DF2 in week prior(a) 1.1 (0.5, 2.3)
Soft drinks 3.8 (2.0, 7.2)
Crumb cake 2.4 (1.2, 4.8)
Ice cream 1.7 (1.1, 3.0)
Cinnamon rolls 1.7 (0.8, 3.7)
Pie 1.5 (0.9, 2.7)
Ice 1.5 (0.8, 2.9)

 Multivariate
Exposure analysis OR

Ever ate at DF1 in week prior(a) 7.3
Ate in DF1 preferentially(b) 2.4
Ever ate at DF2 in week prior(a) 0.6
Soft drinks 2.6
Crumb cake 1.8
Ice cream 1.1
Cinnamon rolls 1.3
Pie 1.1
Ice 1.1


Analysis based on inclusion of 98 "first-wave" cases only, as described in text.

Odds ratios (OR) defined as consumed item vs. did not, in all cells except:

(a) OR = `Yes' vs. `No'; (b) OR = DF1 vs. any other dining facility.

Limited food samples and cultures of the ice cream and soft drink dispensers [ILLEGIBLE TEXT] and sent for analysis--the ice cream dispensers had been turned off and left at [ILLEGIBLE TEXT] temperature for 36 hours before sampling. Post-water production facilities were [ILLEGIBLE TEXT] and water distribution maps were obtained from the Fort Bliss engineers. [ILLEGIBLE TEXT] area had necessitated closure of a nearby water main on August 27, but the main reopened on the same day. Water samples were taken from multiple sites in the [ILLEGIBLE TEXT] compound and elsewhere on post. Stool samples were collected from all hospital and processed for Salmonella, Shigella, Campylobacter, and Yersinia. The first [ILLEGIBLE TEXT] were processed for Aeromonas, Plesiomonas, and Escherichia coli O157:H7, as fecal leukocytes and ova or parasites, including staining for Cyclospora and Cry Twenty-four specimens were also sent to the Centers for Disease Control and [ILLEGIBLE TEXT] (CDC), Atlanta, Georgia, for electron microscopy and PCR testing for NLVs (4).

Of the 222 U.S. soldiers and marines selected to complete a questionnaire as [ILLEGIBLE TEXT] (14.0%) also met the case definition for acute gastroenteritis. Extrapolating to 73 nonhospitalized U.S. soldiers and 24 marines, 106 (14.0%) of 760 would have be [ILLEGIBLE TEXT] to have had unreported illness. Added to the 99 hospitalized troops, this yields a attack rate among all U.S. trainees of (106 + 99) (23.9%) of 859. Of the 15 Japan who were interviewed, nine (60%) had been ill and met the case definition. In all of the 237 controls also met the case definition and were reclassified as case-[ILLEGIBLE TEXT] epidemic curve, based on time of symptom onset in cases, was constructed from identified cases of acute gastroenteritis with completed questionnaires (Figure).

[Figure ILLUSTRATION OMITTED]

Mapping of the outbreak cases demonstrated a discrete geographic clustering in the training compound, with the exceptions of the Japanese soldiers and two U.S. Army officers. Interviews with the Japanese troops found that they all had used DF1 exclusively for morning and evening meals during the week before illness. The two army officers reported eating just one meal at DF1 at lunch on the August 26, with soft drinks and pudding pie as the only food in common. Interviews with food handlers found that a confection baker had become acutely ill while baking in the DF1 facility between 2 a.m. and 4 a.m. on August 26. A DF1 housekeeper (not food handler) also reported August 26. A DF1 housekeeper (not food handler) also reported self-limited gastrointestinal illness between August 27 and August 29. None of the workers in DF2 reported illness.

Univariate analysis of the abstracted questionnaire data showed that soldiers who in the week before the outbreak were 9.8 times as likely to contract acute [ILLEGIBLE TEXT] those who did not use DF1 (95% CI: 2.8, 40.7). Although univariate analysis [ILLEGIBLE TEXT] illness was also associated with eating crumb cake and cinnamon rolls prepared as well as ice cream and soda from DF1, multivariate analysis did not support [ILLEGIBLE TEXT] associations. Multivariate analysis indicated that the best predictors of illness we DF1 and drinking soda from the dining facility (Table 3).

All post-water samples tested negative for fecal coliforms. General sanitation in [ILLEGIBLE TEXT] facilities was satisfactory, and no back-siphoning hazards were found. The soft [ILLEGIBLE TEXT] dispensers had antisiphoning valves. Cultures of food specimens were negative [ILLEGIBLE TEXT] nonpathogenic coliform bacteria (Citrobacter diversus and Serratia liquefaciens) from the ice cream dispenser in DF1 and Enterobacter cloacae coliform bacteria from the soda fountain in DF2. All stool cultures from hospitalized trainees were bacterial fecal pathogens. No ova or parasites, fecal leukocytes, or bacteriologic were found. RT-PCR was positive for NLV2 in 17 of 24 stool specimens submitted for analysis. Electron microscopy was performed on seven specimens, and all we [ILLEGIBLE TEXT] for 30-nm particles consistent with NLV.

Conclusions

This gastroenteritis outbreak was notable for the explosive onset of an intense [ILLEGIBLE TEXT] illness with a short incubation period of 24 to 36 hours. The outbreak curve was of a point-source, propagated, foodborne illness, with clinical and epidemiologic suggestive of NLV gastroenteritis, which was subsequently confirmed by RT-PC

NLVs have been identified as the predominant cause of viral gastroenteritis and implicated in 42% to 96% of nonbacterial gastroenteritis outbreaks since 1976 (5 [ILLEGIBLE TEXT]

Although contaminated water is often the vehicle of outbreaks, the water [ILLEGIBLE TEXT] Bliss is within a closed loop system, and the tight geographic distribution of case inconsistent with proximal contamination of the general water supply. In [ILLEGIBLE TEXT] the dining facilities was not associated with illness (Table 3). Interviews support hypothesis that the outbreak was caused by point-source contamination of food [ILLEGIBLE TEXT] DF1.

Statistical analysis showed a strong association between illness and dining in [ILLEGIBLE TEXT] weaker associations with several food items, particularly crumb cake prepared by confectioner on the morning of August 26 and served at meals on August 26 and weakness of the association could be due in part to recall bias, since the onset of occurred fully a week before the investigation. Both pre- and postsymptomatic [ILLEGIBLE TEXT] of foods has been documented in outbreaks traced to food handlers, which could a few early, sporadic cases before the major outbreak. The strong statistical [ILLEGIBLE TEXT] gastroenteritis with soda drinking suggests contamination of the soft drink [ILLEGIBLE TEXT] a distinct possibility, as NLVs are hardy and persistent in the environment, resist [ILLEGIBLE TEXT] disinfection and chlorination (5,8,10). Bacterial contamination of the ice cream [ILLEGIBLE TEXT] DF1 and the soda fountain in DF2, while an incidental finding, implies that [ILLEGIBLE TEXT] transmission of pathogenic organisms is possible in these facilities. A [ILLEGIBLE TEXT] such as a tendency of ill soldiers to drink more soda, could also explain this [ILLEGIBLE TEXT] Secondary person-to-person transmission promotes viral propagation in outbreak maintains these viruses in circulation. The prompt closure of DF1 and use of [ILLEGIBLE TEXT] medical facilities for quarantine likely decreased secondary propagation in this [ILLEGIBLE TEXT] Limitations of this investigation include inability to identify the viral agent from confection baker, failure to obtain acute- and convalescent-phase sera from ill [ILLEGIBLE TEXT] case-patients, design limitations in using food preferences in the survey, and [ILLEGIBLE TEXT] identify the agent in suspect foods, since NLVs cannot be cultured (5-10).

NLVs are distributed worldwide; serum antibody to Norwalk virus in some [ILLEGIBLE TEXT] approaches 100% seroprevalence in adults. The ubiquitous nature and [ILLEGIBLE TEXT] viral agents make similar future outbreaks of NLV gastroenteritis a near [ILLEGIBLE TEXT] a valuable diagnostic tool in the identification of NLVs as the etiologic agent in [ILLEGIBLE TEXT]

References

(1.) Sharp TW, Thornton SA, Wallace MR, Defraites RF, Sanchez JL, Batchel Diarrheal disease among military personnel during operation Restore Hope 1992-1993. Am J Trop Med Hyg 1995;52:188-93.

(2.) Hyams KC, Hanson RK, Wignall FS, Escamilla J, Oldfield EC. The [ILLEGIBLE TEXT] infectious diseases on the health of U.S. troops deployed to the Persian [ILLEGIBLE TEXT] operations Desert Shield and Desert Storm. Clin Infect Dis 1995 ;20:1497-[ILLEGIBLE TEXT] Warner RD, Carr RW, McClesky FK, Johnson PC, Goldy-Elmer LM, [ILLEGIBLE TEXT] large nontypical outbreak of Norwalk virus: gastroenteritis associated with celery to nonpotable water and with Citrobacter freundii. Arch Intern Med 1991;151:2419-24.

(4.) Ando T, Monroe SS, Gentsch JR, Jin Q, Lewis DC, Glass RI. Detection an differentiation of antigenically distinct small round-structured viruses [ILLEGIBLE TEXT] viruses) by reverse transcription-PCR and Southern hybridization. J Clin 1995;33:64-71.

(5.) Kapikian AZ, Estes MK, Chanock RM. Norwalk group of viruses. In: [ILLEGIBLE TEXT] Knipe DM, Howley PM, Chanock M, Melnick JL, Monath TP, et al, editor Virology. 3rd ed. Philadelphia (PA): Lippincott-Raven Publishers; 1996. [ILLEGIBLE TEXT]

(6.) Caul EO. Viral gastroenteritis: small round structured viruses, caliciviruse astroviruses. Part I. The clinical and diagnostic perspective. J Clin Pathol [ILLEGIBLE TEXT] 80.

(7.) Caul EO. Viral gastroenteritis: small round structured viruses, caliciviruse astroviruses. Part II. The epidemiological perspective. J Clin Pathol 1996;

(8.) Hedberg CW, Osterholm MT. Outbreaks of food-borne and waterborne [ILLEGIBLE TEXT] gastroemeritis. Clin Micro Reviews 1993;6:199-210.

(9.) Kapikian AZ. Viral Gastroenteritis. JAMA 1993;269:627-30.

(10.) Centers for Disease Control. Viral agents of gastroenteritis: public health [ILLEGIBLE TEXT] and outbreak management. MMWR Morb Mortal Wkly Rep 1990;39(RR-[ILLEGIBLE TEXT]

(11.) Kaplan JE, Feldman R, Campbell DS, Lookabaugh C, Gary GW. The [ILLEGIBLE TEXT] Norwalk-like pattern of illness in outbreaks of acute gastroenteritis. AJPH 1982;72:1329-32.

(12.) Kaplan JE, Gary GW, Baron RC, Singh N, Schonberger LB, Feldman R, [ILLEGIBLE TEXT] Epidemiology of Norwalk gastroenteritis and the role of Norwalk virus in acute nonbacterial gastroenteritis. Ann Intern Med 1982;96:756-61.

(13.) Adler JL, Zickl R. Winter vomiting disease. J Infect Dis 1969;119:668-73.

(14.) Kapikian AZ, Wyatt RG, Dolin R, Thornhill TS, Kalica AR, Chanock RM Visualization by immune electron microscopy of a 27-nm particle [ILLEGIBLE TEXT] acute infectious nonbacterial gastroenteritis. J Virol 1972;10:1075-81.

Mark K. Arness,(*) Brian H. Feighner,([dagger]) Michelle L. Canham,([dagger]) David N. Taylor,([double dagger]) Stephan S. Monroe,([sections]) Theodore J. Cieslak([paragraph]) Edward L. Hoedebecke,([dagger]) Christina S. Polyak,([dagger]) Judy C. Cuthie,([dagger]) Rebecca L. Fankhauser,([sections]) Charles D. Humphrey,([sections]) Tamra L. Barker,(#) Chris D. Jenkins,(#) and Donald R. Skillman(#)

(*) Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA; ([dagger]) U.S. Army Center for Health Promotion and Preventive Medicine, Edgewood, Maryland, USA; ([double dagger]) Walter Reed Army Institute of Research, Washington, D.C., USA; ([sections]) Centers for Disease Control and Prevention, Atlanta, Georgia, USA; ([paragraph]) U.S. Army Medical Research Institute of Infectious Diseases, Frederick, Maryland, USA; and #William Beaumont Army Medical Center, El Paso, Texas, USA
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Author:Skillman, Donald R.
Publication:Emerging Infectious Diseases
Geographic Code:1USA
Date:Mar 1, 2000
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