Unspecified Gastroenteritis Illness and Deaths in the Elderly Associated With Norovirus Epidemics

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Abstract
New variant strains of norovirus have emerged worldwide in recent years, evolving by mutation much like influenza viruses. These strains have been associated with a notable increase in the number of annual norovirus outbreaks. However, the impact of such increased norovirus activity on morbidity and mortality is not clear because norovirus infection is rarely specifically registered. We studied trends of gastroenteritis with unspecified cause in medical registrations (ie, general practitioner [GP] visits, hospitalizations, and deaths) and their association with known temporal trends in norovirus outbreaks in the Netherlands. Using weekly counts in the elderly (aged 65+ years) from 1999 through 2006, we applied Poisson regression analyses adjusted for additional pathogens and seasonal trends (linear, sine, and cosine terms). In the elderly, each notified norovirus outbreak was associated with an estimated 26 unspecified gastroenteritis GP visits (95% confidence interval = 17-34), 2.2 unspecified gastroenteritis hospitalizations (1.6-2.7), and 0.14 unspecified gastroenteritis deaths (0.08-0.21). For the heaviest norovirus season (2004-2005), these models attributed up to 3804 unspecified gastroenteritis GP visits, 318 unspecified gastroenteritis hospitalizations, and 21 unspecified gastroenteritis deaths to norovirus outbreaks among a total elderly population of 2.3 million. The recent increase in norovirus outbreak activity is associated with increases of unspecified gastroenteritis morbidity and even deaths in the elderly. Norovirus should not be regarded as an infection with trivial health risks.