Waterborne Outbreak of Gastroenteritis Associated with a Norovirus

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Abstract
The Wyoming Department of Health investigated an outbreak of acute gastroenteritis among persons who dined at a tourist saloon in central Wyoming during October 2001. Human caliciviruses (HuCVs) were suspected as the etiological agent of the outbreak based on the incubation period, duration of illness, and symptoms observed in ill patrons. A retrospective cohort study demonstrated that ill patrons were 4.5 times more likely to have exposure to drinking water and/or ice than nonill patrons. No food items were associated with illness. An environmental investigation gave evidence that the saloon's groundwater was contaminated with sewage. Water from the saloon's only well was processed for viruses. The processed water sample and stool samples collected from three ill patrons were analyzed by reverse transcription-PCR (RT-PCR) for the presence of HuCV. All positive RT-PCR results were confirmed by sequence and phylogenetic analyses of cloned RT-PCR products. A genogroup I, subtype 3, HuCV stain was found to be present in the well water sample and two stool samples. In addition, a genogroup II, subtype 6, strain was detected in one stool sample. The identification of the same HuCV strain in both the well water and stool samples strongly suggests a link between exposure to well water and the outbreak of gastroenteritis. The presence of a genogroup II, subtype 6, strain in one of the stool samples suggests that multiple HuCV strains may have been involved in this outbreak. The laboratory isolation of HuCV strains from outbreak-associated drinking water is relatively novel in the United States. This investigation outlines the procedure for virus isolation and illustrates the utility of RT-PCR for the identification of HuCV in large volumes of water and stool samples obtained during outbreaks of acute nonbacterial gastroenteritis.