Wedding Day Blues (and greens, and oranges, and reds) - PowerPoint PPT Presentation


Title: Wedding Day Blues (and greens, and oranges, and reds)


1
Wedding Day Blues(and greens, and oranges, and
reds)
2
The Day Before.
  • Practice wedding dinner activity
  • Groom developed intestinal turbulence
  • jittery nerves or something he ate?
  • No more guys night out
  • Have to share the remote control
  • Loss of manly freedom

3
During the wedding dinner
  • upchuck barf vomit hurl ralph purge puke
    hork buick spew regurgitate throw up toss
    your cookies lose your lunch toss a sidewalk
    pizza tango with the toilet make modern art in
    the toilet have a technicolor yawn expunge the
    contents of your stomach
  • bare your guts to the world become a
    multicolored organic fountain revisit your
    breakfast vomit your victuals drive the
    porcelain bus perform peristaltic pyrotechnics
    paint the town red.. and green and orange and
    pink have to say "that tasted better going down
    than coming up" burp to the ninth power make
    the janitor get out the ol sawdust bucket find
    out just how acidic your stomach contents are
    greet your guts pray to the porcelain god

UP
4
A few days later
  • Other wedding dinner guests wanted to share the
    pain
  • vomiting
  • diarrhea (bloody)
  • porcelain throne - best friend
  • Talked to Ralph on the big white phone
  • symptoms occurred 1-2 days after the wedding
    dinner
  • duration of 1- 4 days

5
Possible Causes of Illness
  • Salmonella
  • Campylobacter
  • Shigella
  • Bacillus
  • Vibrio
  • Listeria
  • Hepatitis A
  • Enterovirus
  • Norovirus
  • Rotavirus
  • Intentional contamination by former
    spouse/girlfriend

6
Most likely food products
  • shellfish
  • chicken
  • eggs
  • chocolate milk
  • fried rice
  • undercooked beef
  • Unpasteurized apple cider
  • lettuce
  • alfalfa sprouts
  • unwashed fruit
  • other food contaminated by foodhandler

7
Solved by Committee
  • County food poisoning hotline
  • complaints about an institution
  • Epidemiologists (county and state)
  • track contacts, point of origin, review common
    patient symptoms, ask for specimens

8
Solved by Committee
  • State lab
  • coordinate all activities and ship out specimens
  • CDC
  • identification of causative agent

9
Specifics
  • 131 people reported some illness (self reported
    or contacted by epidemiology)
  • Food institution voluntarily shut down to review
    procedures and disinfect
  • Food institution reopened - people became ill
    again
  • Shut down for one month for more thorough
    cleansing, new carpeting

10
Specifics
  • No one food item could be narrowed down
  • Food institution tried to blame it on the groom -
    projectile vomiting, aerosolization of agent
  • Food handlers later determined to be ill before
    the outbreak
  • CDC determined agent to be Norwalk virus

11
Evidence for airborne transmission of NLV in a
hotel restaurant Epidemiol Infect 124481-487
  • Woman abruptly vomited at her table during dinner
  • Staff cleaned it up quickly and the meal
    continued
  • A few days later several other people started
    getting various similar symptoms
  • Reported to health authorities investigation
    began
  • People at the same table 91 ill
  • 1 table away on both sides 60-69 ill
  • 2 tables away on either side 40-45 ill
  • Food service workers 15 ill moved between
    tables
  • No suspect food products, no previously ill
    workers
  • Stools specimens showed 100 match between
    patients
  • Aerosolization of vomitus most likely cause!

12
What are Noroviruses?
  • Noroviruses are a group of viruses that cause
    acute gastroenteritis in humans.
  • The symptoms of norovirus infection include
    nausea, vomiting, diarrhea, cramping, and
    low-grade fever.
  • Noroviruses are transmitted through the
    fecal-oral route, either by consumption of
    fecally contaminated food or water, direct
    person-to-person spread, or environmental and
    fomite contamination.

13
Epidemiology
  • Norwalk virus
  • 23 million cases/year
  • 96 of nonbacterial gastroenteritis outbreaks
  • Crowding and poor sanitation
  • High attack rates
  • Low infectious dose

14
Microbiology
  • Caliciviridae small round viruses
  • 32 nm w/ an amorphous surface and ragged outline
  • No known reservoir outside of humans
  • Earlier designations Norwalk virus
  • Norwalk OH prototype virus 11 varieties
  • Norwalk like viruses noroviruses
  • Named for where first detected Snow Mountain,
    Hawaii, Montgomery County, Oklahoma, Sapporo, etc

15
Pathogenesis
  • Blunting of villi, cytoplasmic vacuolation, and
    infiltration with mononuclear cells

16
Specimens
  • Collected as soon as gastroenteritis diagnosed
  • Within 48 hours of illness
  • Stool specimens, ileostomy contents, bowel
    contents
  • Relatively stable - 4C 1 week

17
Diagnosis
  • Gastrointestinal viruses
  • Electron microscopy - EM or IEM
  • Antigen detection
  • Serology
  • Molecular assays RT-PCR

18
Electron Microscopy
  • Viruses easily recognizable
  • 106 - 107quantity corresponds to active vs
    asymptomatic infection
  • Solid Phase immune electron microscopy
  • EM grid coated with Ab to virus to capture viral
    particles
  • Enhances specificity, can type calici and NLV
  • JCM 33501-4

19
Antigen Detection
  • ELISA
  • Latex agglutination
  • Rapid tests also available
  • Commercial assays available for Adenovirus,
    Astrovirus, and Norwalk virus
  • No commercial assays available for other
    caliciviruses

20
Serology
  • Capture IgM assay 62 natural infection, 94
    experimental infection
  • J Virol Methods 2457-66
  • Timing of serum collection important
  • JCM 372983-6
  • Capture IgM better for diagnosis
  • JCM 361064-9, J Infect Dis 170535-42

21
Molecular Assays
  • RNA PAGE - silver staining
  • Restriction enzyme analysis
  • Dot blot assays ELISA
  • PCR - gt sensitivity over ELISA
  • definitive method, most sensitive 102 - 104
    particles/ml
  • inhibitors removed with better processing

22
Treatment
  • Gastrointestinal viruses
  • No specific treatment available
  • Supportive therapy
  • Bismuth salicylate may reduce GI symptoms

23
Prevention and Control
  • Gastroenteritis viruses
  • Careful handling of food
  • Maintain purity of water supply
  • Handwashing
  • Improvements in hygiene
  • Infection control methods for reducing outbreaks

24
Prevention and Control
  • Potential vaccine
  • Intranasally delivered dry powder
  • Lyophilized virus particles conformation of the
    viral capsid
  • Phase 1 safety trials immunogenic
  • Live virus challenge studies forthcoming
  • Greatest effects on pediatric and geriatric
    populations

25
Disinfection!
  • Doorknobs, faucets, sinks, toilets, commodes,
    bath rails, phones, counters, chairs (including
    backs), tables, hand rails, elevator buttons,
    light switches, keyboards, mattress covers,
    aprons, uniforms, linens, bedding and ice
    machines.
  • Hard surfaces
  • Carpet / Upholstered Furniture
  • Linens / clothing / textiles

26
Food Handler Issues
  • Food handlers who are ill with gastrointestinal
    symptoms MUST NOT prepare or serve food for
    others under any circumstances
  • Any employee with vomiting or diarrhea must be
    sent home immediately, unless their symptoms are
    the result of a non-infectious condition (e.g.,
    pregnancy or Crohns Disease).
  • Employees that have been ill with suspected
    Norovirus MUST not return to work for a period of
    24 hours after symptoms have ended or provides
    medical documentation that the symptom is from a
    non-infectious condition.

27
Cruise Line Data
  • 10 year span
  • 208 foodborne outbreaks
  • 142 confirmed Norovirus infections
  • Top 5 cruise lines
  • 39, 30, 25, 17, 12 outbreaks
  • Several on same boats
  • Some had to be taken off service for full
    cleaning
  • CDC provides info for free

28
Case Report
  • BSA National Jamboree Fort AP Hill 2001
  • 40,000 campers, 20 subcamps, 600 groups of 40-90
    campers
  • Day 1 medical screening - rashes, vomiting,
    diarrhea, fever, HA, cough
  • 6/80 grp A, 15/84 grp B - vomiting, diarrhea
  • Day 2 6/80 grp C - vomiting, diarrhea
  • Overall attack rates 10/80 grp A, 26/84 grp B,
    22/80 grp C

29
Case Report
  • 8 stool samples collected, 6/8 NLV () by RT-PCR,
    confirmed at CDC, genetically identical
  • Affected campers excluded from camp activities
    with potential for transmission
  • water sports, archery, shooting
  • Affected groups provided with dedicated latrines,
    washing facilities, drinking water
  • Shower space reserved for affected members,
    facilities cleaned with 10 bleach

30
Case Report
  • Hand washing stressed for all members of affected
    groups
  • Well group members - enteric precautions
  • Outbreaks lasted 4-9 days
  • Final evening 36 campers in same subgroup as grp
    A - vomiting and diarrhea
  • point source outbreak
  • Infection control in action! Intervention efforts
    effective.
  • MMWR 51661-3
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Wedding Day Blues (and greens, and oranges, and reds)

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Title: Wedding Day Blues (and greens, and oranges, and reds)


1
Wedding Day Blues(and greens, and oranges, and
reds)
2
The Day Before.
  • Practice wedding dinner activity
  • Groom developed intestinal turbulence
  • jittery nerves or something he ate?
  • No more guys night out
  • Have to share the remote control
  • Loss of manly freedom

3
During the wedding dinner
  • upchuck barf vomit hurl ralph purge puke
    hork buick spew regurgitate throw up toss
    your cookies lose your lunch toss a sidewalk
    pizza tango with the toilet make modern art in
    the toilet have a technicolor yawn expunge the
    contents of your stomach
  • bare your guts to the world become a
    multicolored organic fountain revisit your
    breakfast vomit your victuals drive the
    porcelain bus perform peristaltic pyrotechnics
    paint the town red.. and green and orange and
    pink have to say "that tasted better going down
    than coming up" burp to the ninth power make
    the janitor get out the ol sawdust bucket find
    out just how acidic your stomach contents are
    greet your guts pray to the porcelain god

UP
4
A few days later
  • Other wedding dinner guests wanted to share the
    pain
  • vomiting
  • diarrhea (bloody)
  • porcelain throne - best friend
  • Talked to Ralph on the big white phone
  • symptoms occurred 1-2 days after the wedding
    dinner
  • duration of 1- 4 days

5
Possible Causes of Illness
  • Salmonella
  • Campylobacter
  • Shigella
  • Bacillus
  • Vibrio
  • Listeria
  • Hepatitis A
  • Enterovirus
  • Norovirus
  • Rotavirus
  • Intentional contamination by former
    spouse/girlfriend

6
Most likely food products
  • shellfish
  • chicken
  • eggs
  • chocolate milk
  • fried rice
  • undercooked beef
  • Unpasteurized apple cider
  • lettuce
  • alfalfa sprouts
  • unwashed fruit
  • other food contaminated by foodhandler

7
Solved by Committee
  • County food poisoning hotline
  • complaints about an institution
  • Epidemiologists (county and state)
  • track contacts, point of origin, review common
    patient symptoms, ask for specimens

8
Solved by Committee
  • State lab
  • coordinate all activities and ship out specimens
  • CDC
  • identification of causative agent

9
Specifics
  • 131 people reported some illness (self reported
    or contacted by epidemiology)
  • Food institution voluntarily shut down to review
    procedures and disinfect
  • Food institution reopened - people became ill
    again
  • Shut down for one month for more thorough
    cleansing, new carpeting

10
Specifics
  • No one food item could be narrowed down
  • Food institution tried to blame it on the groom -
    projectile vomiting, aerosolization of agent
  • Food handlers later determined to be ill before
    the outbreak
  • CDC determined agent to be Norwalk virus

11
Evidence for airborne transmission of NLV in a
hotel restaurant Epidemiol Infect 124481-487
  • Woman abruptly vomited at her table during dinner
  • Staff cleaned it up quickly and the meal
    continued
  • A few days later several other people started
    getting various similar symptoms
  • Reported to health authorities investigation
    began
  • People at the same table 91 ill
  • 1 table away on both sides 60-69 ill
  • 2 tables away on either side 40-45 ill
  • Food service workers 15 ill moved between
    tables
  • No suspect food products, no previously ill
    workers
  • Stools specimens showed 100 match between
    patients
  • Aerosolization of vomitus most likely cause!

12
What are Noroviruses?
  • Noroviruses are a group of viruses that cause
    acute gastroenteritis in humans.
  • The symptoms of norovirus infection include
    nausea, vomiting, diarrhea, cramping, and
    low-grade fever.
  • Noroviruses are transmitted through the
    fecal-oral route, either by consumption of
    fecally contaminated food or water, direct
    person-to-person spread, or environmental and
    fomite contamination.

13
Epidemiology
  • Norwalk virus
  • 23 million cases/year
  • 96 of nonbacterial gastroenteritis outbreaks
  • Crowding and poor sanitation
  • High attack rates
  • Low infectious dose

14
Microbiology
  • Caliciviridae small round viruses
  • 32 nm w/ an amorphous surface and ragged outline
  • No known reservoir outside of humans
  • Earlier designations Norwalk virus
  • Norwalk OH prototype virus 11 varieties
  • Norwalk like viruses noroviruses
  • Named for where first detected Snow Mountain,
    Hawaii, Montgomery County, Oklahoma, Sapporo, etc

15
Pathogenesis
  • Blunting of villi, cytoplasmic vacuolation, and
    infiltration with mononuclear cells

16
Specimens
  • Collected as soon as gastroenteritis diagnosed
  • Within 48 hours of illness
  • Stool specimens, ileostomy contents, bowel
    contents
  • Relatively stable - 4C 1 week

17
Diagnosis
  • Gastrointestinal viruses
  • Electron microscopy - EM or IEM
  • Antigen detection
  • Serology
  • Molecular assays RT-PCR

18
Electron Microscopy
  • Viruses easily recognizable
  • 106 - 107quantity corresponds to active vs
    asymptomatic infection
  • Solid Phase immune electron microscopy
  • EM grid coated with Ab to virus to capture viral
    particles
  • Enhances specificity, can type calici and NLV
  • JCM 33501-4

19
Antigen Detection
  • ELISA
  • Latex agglutination
  • Rapid tests also available
  • Commercial assays available for Adenovirus,
    Astrovirus, and Norwalk virus
  • No commercial assays available for other
    caliciviruses

20
Serology
  • Capture IgM assay 62 natural infection, 94
    experimental infection
  • J Virol Methods 2457-66
  • Timing of serum collection important
  • JCM 372983-6
  • Capture IgM better for diagnosis
  • JCM 361064-9, J Infect Dis 170535-42

21
Molecular Assays
  • RNA PAGE - silver staining
  • Restriction enzyme analysis
  • Dot blot assays ELISA
  • PCR - gt sensitivity over ELISA
  • definitive method, most sensitive 102 - 104
    particles/ml
  • inhibitors removed with better processing

22
Treatment
  • Gastrointestinal viruses
  • No specific treatment available
  • Supportive therapy
  • Bismuth salicylate may reduce GI symptoms

23
Prevention and Control
  • Gastroenteritis viruses
  • Careful handling of food
  • Maintain purity of water supply
  • Handwashing
  • Improvements in hygiene
  • Infection control methods for reducing outbreaks

24
Prevention and Control
  • Potential vaccine
  • Intranasally delivered dry powder
  • Lyophilized virus particles conformation of the
    viral capsid
  • Phase 1 safety trials immunogenic
  • Live virus challenge studies forthcoming
  • Greatest effects on pediatric and geriatric
    populations

25
Disinfection!
  • Doorknobs, faucets, sinks, toilets, commodes,
    bath rails, phones, counters, chairs (including
    backs), tables, hand rails, elevator buttons,
    light switches, keyboards, mattress covers,
    aprons, uniforms, linens, bedding and ice
    machines.
  • Hard surfaces
  • Carpet / Upholstered Furniture
  • Linens / clothing / textiles

26
Food Handler Issues
  • Food handlers who are ill with gastrointestinal
    symptoms MUST NOT prepare or serve food for
    others under any circumstances
  • Any employee with vomiting or diarrhea must be
    sent home immediately, unless their symptoms are
    the result of a non-infectious condition (e.g.,
    pregnancy or Crohns Disease).
  • Employees that have been ill with suspected
    Norovirus MUST not return to work for a period of
    24 hours after symptoms have ended or provides
    medical documentation that the symptom is from a
    non-infectious condition.

27
Cruise Line Data
  • 10 year span
  • 208 foodborne outbreaks
  • 142 confirmed Norovirus infections
  • Top 5 cruise lines
  • 39, 30, 25, 17, 12 outbreaks
  • Several on same boats
  • Some had to be taken off service for full
    cleaning
  • CDC provides info for free

28
Case Report
  • BSA National Jamboree Fort AP Hill 2001
  • 40,000 campers, 20 subcamps, 600 groups of 40-90
    campers
  • Day 1 medical screening - rashes, vomiting,
    diarrhea, fever, HA, cough
  • 6/80 grp A, 15/84 grp B - vomiting, diarrhea
  • Day 2 6/80 grp C - vomiting, diarrhea
  • Overall attack rates 10/80 grp A, 26/84 grp B,
    22/80 grp C

29
Case Report
  • 8 stool samples collected, 6/8 NLV () by RT-PCR,
    confirmed at CDC, genetically identical
  • Affected campers excluded from camp activities
    with potential for transmission
  • water sports, archery, shooting
  • Affected groups provided with dedicated latrines,
    washing facilities, drinking water
  • Shower space reserved for affected members,
    facilities cleaned with 10 bleach

30
Case Report
  • Hand washing stressed for all members of affected
    groups
  • Well group members - enteric precautions
  • Outbreaks lasted 4-9 days
  • Final evening 36 campers in same subgroup as grp
    A - vomiting and diarrhea
  • point source outbreak
  • Infection control in action! Intervention efforts
    effective.
  • MMWR 51661-3
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