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Norovirus…common, but one of the most contagious food-borne disease

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One of the world’s biggest cruise ships, Royal Caribbean’s Oasis of the Seas, which had set out on a tour of a number of Caribbean islands, was recently forced to return to its Florida home port a day early after guests and crew members were hit with an outbreak of norovirus, commonly known as “stomach flu”.

One of the most contagious of food-borne diseases, norovirus gastroenteritis is a common disease worldwide, affecting all age groups and often causing outbreaks.

With increased numbers of norovirus cases on land, reported across the United States, Canada and Japan, the International Council of Cruise Lines has observed a corresponding increase in norovirus incidents on-board cruise ships. While annually, less than one per cent of all cruise ship passengers have been affected by norovirus, cruise lines encourage all people — cruise passengers or not — to practise good hygiene by washing hands frequently and thoroughly with soap and water.

According to the Pan American Health Organization (PAHO), molecular epidemiological studies have documented a high genetic diversity of norovirus with the regular emergence of different forms of the virus. It has been suggested that the emergence of new variants causes an increase in cases.

Passengers and crew on the Oasis of the Seas began getting sick while the ship was en route to its first destination. When it arrived at the Falmouth Pier in Jamaica, after stopping in Haiti, passengers were not allowed to leave the vessel for fear of spreading the disease to persons on shore.

The cruise company initially said 277 passengers on the ship were afflicted with norovirus, but this figure has swelled. A spokesman said returning to port early gave the cruise line “more time to completely clean and sanitise the ship” before it set sail with a new batch of passengers.

 

Symptoms

Norovirus is the most common cause of food-borne illness. Symptoms include griping, diarrhoea, vomiting, nausea, and stomach pain. They may also include fever, headache and body aches. The virus may cause acute gastroenteritis, which is inflammation of the stomach or intestines. It can also cause dehydration, whereby patients experience decrease in urination, dry mouth and throat, and dizziness when standing up.

Norovirus can be more serious for young children, the elderly, and people with other health conditions. It can lead to severe dehydration, hospitalisation, and even death. Children who are dehydrated may be unusually sleepy or fussy.

Symptoms usually appear 12 to 48 hours after exposure to the virus; most people affected with the illness get better within one to three days.

 

How it spreads

Norovirus can be found in vomit or faeces even before you start feeling sick. The virus can also show up in bodily waste two weeks or even more after you feel better. A person can become infected through having direct contact with another infected person, consuming contaminated food or water, or touching their nose and mouth after coming in contact with contaminated surfaces.

Norovirus can easily contaminate food and water because it only takes a very small amount of virus particles to make you sick. Food and water can get contaminated with norovirus in many ways, including when an infected person touches food with their bare hands that have faeces or vomit particles on them, or when food is placed on an infected surface.

Because symptoms come on very suddenly, an infected person who vomits in a public place may infect many people. Vomiting from an infected person tends to gush out of the mouth, and tiny drops of vomit spray can travel through the air, land on food and infect it with the virus.

Food that is grown or harvested with contaminated water, such as harvested oysters, or fruit and vegetables irrigated with contaminated water in the field may also carry the virus.

For the most part, norovirus outbreaks occur in food service settings like restaurants. Infected food workers are frequently the source of outbreaks, often by touching ready-to-eat foods, such as raw fruits and vegetables, with their bare hands before serving them. However, any food served raw or handled after being cooked can become contaminated.

Norovirus can also spread through contaminated drinking water or recreational water such as swimming. This can happen when a septic tank leaks into a well; when an infected person releases body waste in the water or when water; is not properly treated, as is the case with insufficient chlorine.

 

Preventing the spread

There is currently no vaccine to prevent norovirus, although this is an area of active research.

You can help protect yourself and others from norovirus by practising proper hand hygiene. Wash your hands thoroughly with soap and water, especially after using the toilet or changing diapers. Wash hands always before eating, preparing, or handling food. You can use alcohol-based hand sanitisers in addition to hand-washing. But, you should not use hand sanitisers as a substitute for washing your hands with soap and water, because they are not as effective at removing norovirus-infected particles.

Be sure to carefully wash fruits and vegetables before preparing and eating them. Oysters and shellfish need to be thoroughly cooked before they are ready for consumption. Be aware that noroviruses are relatively resistant to heat. They can survive temperatures as high as 145°F and quick-steaming processes that are often used for cooking shellfish.

You should not prepare food for others or provide health care while you are sick and for at least two days after symptoms stop. This also applies to sick workers in restaurants, schools, day cares, long-term care facilities, and other places where they may expose people to norovirus. Keep sick infants and children out of areas where food is being handled and prepared.

To ensure that food is safe from norovirus and other food-borne diseases, you should routinely clean and sanitise kitchen utensils, counters, and surfaces before preparing food. Use a chlorine bleach solution with a concentration of five to 25 tablespoons of household bleach per gallon of water, or other effective disinfectant.

Wash laundry thoroughly. Immediately remove and wash clothes or linens that may be contaminated with vomit or faeces. You should wear rubber or disposable gloves while handling soiled items, and wash the items with detergent and hot water at the maximum available cycle length, then machine-dry them at the highest heat setting.

The PAHO/World Health Organization (WHO) recommends that member states implement prevention and control in health care and gated communities to reduce the impact caused by norovirus outbreaks.

 

Not a cruise ship illness

According to Dave Forney, chief of the Vessel Sanitation Program of the US Centers for Disease Control and Prevention (CDC), norovirus is not a cruise ship illness, but an illness commonly seen in many settings. However, he noted that cruise lines have taken a leadership role in addressing norovirus. “Cruise ships have rigorous protocols and procedures in place to manage and eradicate transmission of norovirus,” Forney said. “In addition to being held to the highest sanitation standards in the world, cruise lines have worked meticulously and effectively to actually break the cycle of transmission during most cruises, which requires a lot of effort and expertise.”

Weighing in on the issue of food-borne illnesses, Helen Kennedy, Technological Solutions Limited’s (TSL) manager, technical & consulting services – southern Caribbean, agrees that the norovirus does not only occur on cruise ships, but could be spread throughout other food establishments such as restaurants as well as hotels. Kennedy, along with other TSL team members, who are qualified, experienced and competent food safety professionals, provide a variety of services to help those in the restaurant and food services business conform to international best practices.

“We would love to see food establishments throughout the Caribbean and beyond provide food that will never make anyone ill,” says Kennedy.

The TSL team keeps its ears close to the ground to identify the changes in international requirements, such as the Food Modernization Act, which requires that food facilities have food safety plans that set forth how they will identify and minimise hazards.

Some of the strategies employed by TSL include:

• identifying and working with public health bodies across the region to ensure that food establishments have measures in place that are critical to their food service operations;

• assisting food establishments to make corrective measures where necessary and followup to ensure that these have in fact been done;

• training that is tailored to their needs;

• analytical support; and

• laboratory services.

 

Dr Wendy-Gaye Thomas is group technical manager, Technological Solutions Limited, a Jamaican food technology company. She can be contacted at wendy.thomas@tsltech.com.

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