Norovirus Literature Review PDF

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In healthcare settings, what is the current

epidemiology and latest evidence on transmission
pathways and infection prevention and control
measures for Norovirus Gastroenteritis?
Literature Review
Prepared for
National Health and Medical Research Council (NHMRC)
Submitted by
University of South Australia
Division of Health Sciences
Submission date
21st April 2017
University of South Australia 2017

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Table of Contents
Background ............................................................................................................................................. 3
Objectives ............................................................................................................................................... 4
Methods.................................................................................................................................................. 4
Results..................................................................................................................................................... 5
Review questions 1 and 2 ................................................................................................................... 5
Characteristics of included studies ..................................................................................................... 7
Healthcare settings ............................................................................................................................. 8
Q 1: Epidemiology for Norovirus Gastroenteritis in healthcare settings ............................................. 9
Norovirus detection methods ............................................................................................................. 9
Prevalence of Norovirus Geno-groups.............................................................................................. 12
Clinical features of norovirus gastroenteritis in outbreaks .............................................................. 14
Q 2: Transmission pathways for Norovirus Gastroenteritis in healthcare settings ........................... 15
Transmission pathways ..................................................................................................................... 15
NoV Shedding in healthcare settings ................................................................................................ 17
Results................................................................................................................................................... 19
Q 3: Infection prevention and control strategies ................................................................................ 19
Characteristics of included studies ................................................................................................... 20
Healthcare settings ........................................................................................................................... 20
NoV Infection prevention and control strategies in healthcare settings ........................................... 21
The effectiveness of hand sanitizers ................................................................................................. 21
The effectiveness of ward or bay closures........................................................................................ 22
Environmental cleaning .................................................................................................................... 23
Other infection control strategies .................................................................................................... 24
Discussion ............................................................................................................................................. 28
References ............................................................................................................................................ 31

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In healthcare settings, what is the current epidemiology and latest evidence on

transmission pathways and infection prevention and control measures for
Norovirus Gastroenteritis?
Review Team:
Dr Rasika Jayasekara1 (Project Leader)
Dr David Evans 1
Associate Professor Kay Price1
Expert Advisors:
Marija Juraja - Clinical Service Coordinator for Central Adelaide Local Health Network, Infection
Prevention and Control Unit
Dr Rietie Venter - Microbiologist and Senior Lecturer in Microbiology, School of Pharmacy and
Medical Science, Division of Health Sciences, University of South Australia
Literature Search
Carole Gibbs, Academic Librarian, University of South Australia
Kate Kennedy, Research Assistant1
1
School of Nursing & Midwifery, Division of Health Sciences, University of South Australia
--------------------------------------------------------------------------------------------------------------------------------------------------
Background
The National Health and Medical Research Council (NHMRC) commissioned this independent
literature review to provide assurance that the revision of the Australian Guidelines for the
Prevention and Control of Infection in Healthcare is grounded in the most up-to-date and relevant
scientific evidence.
Norovirus is the most frequently occurring cause of community-acquired acute gastroenteritis in

people of all ages. It is also one of the most frequent causes of outbreaks in healthcare settings,
affecting both long-term care facilities and acute care hospitals (Kambhampati, Koopmans & Lopman
2015; Lindsay et al. 2015) These outbreaks lead to patient morbidity resulting in extended length of
stay and occasionally mortality (Sadique et al. 2016). Norovirus outbreaks also cause additional costs
associated with treatment provision and bed-days lost due to temporary closure of wards, as well as
productivity losses associated with infected hospital staff (Harris 2016; NHMRC 2010; Sadique et al.
2016; Zheng et al. 2015). It is evident that prevalence of norovirus infection in the community is high
and it is difficult to prevent the infection because persons may shed the virus without being ill, and
transmission occurs not only through direct and indirect person-to-person contact, but also through
food, water, surfaces and aerosols (NHMRC 2010; Petrignani et al. 2015; Rahamat-Langendoen et al.
2013). Therefore, it is important to explore the current epidemiology and latest evidence on
transmission pathways and infection prevention and control measures for Norovirus Gastroenteritis.
The purpose of this literature review was to identify the current epidemiology of norovirus infection
and transmission of disease within healthcare setting including acute care, aged care, paediatric,
neonatal and rehabilitation settings. In addition, this literature review examined the available
evidence on transmission based precautions methods and infection control measures. The literature
review will contribute to a discussion paper that will identify key areas that need updating, or

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further consideration within the Australian Guidelines for the Prevention and Control of Infection in
Healthcare (2010).
Objectives
The purpose of this literature review was to examine the current epidemiology and latest evidence
on transmission pathways and infection prevention and control measures for Norovirus
Gastroenteritis.
Specifically, the three review questions of this literature review were:

Q 1: What is the current epidemiology (clinical features, occurrence diagnostics/Screening
strategies) for Norovirus Gastroenteritis in acute care, aged care, paediatric, neonatal
and rehabilitation settings?
Q 2: What is the latest evidence on transmission pathways for Norovirus Gastroenteritis in
acute care, aged care, paediatric, neonatal and rehabilitation settings?
Q 3: What are the infection prevention and control strategies (eg disinfection bleach vs
other, frequency of cleaning, hand hygiene alcohol vs soap/water,) for Norovirus
Gastroenteritis in acute care, aged care, paediatric, neonatal and rehabilitation
settings?
Methods
This literature review was conducted using a documented search strategy, inclusion and exclusion
criteria, critical appraisal methodology and evidence synthesis and practice recommendations. The
review method utilised Cochrane Handbook for Systematic Reviews of Interventions (Higgins &
Green 2011) in particular; the Cochrane Public Health Group: Guide for developing a Cochrane
protocol (2011); “How to review the evidence: systematic identification and review of the scientific
literature”(NHMRC 1999). “NHMRC additional levels of evidence and grades for recommendations
for developers of guidelines (NHMRC 2000) and The Joanna Briggs Institute Reviewers’ Manual 2014
-The Systematic Review of Prevalence and Incidence Data (JBI 2014).
Please refer the Technical Report for detailed review process.
Inclusion and exclusion criteria for considering studies for this review
This review considered all relevant studies regardless of publication status (published, unpublished,
in press, and ongoing) within the last 10 years, from 2006 to 2016. There was no search time limit for
randomized controlled trials (RCTs). The search was limited to human and English language
publications.

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Review Condition Context Population Outcomes Study Designs

question
Q1 Norovirus epidemiology all type of incidence, all types of
Gastroenteri (clinical patients/partic prevalence, observational
tis features, ipants frequency of studies -prospective
occurrence including outbreaks and retrospective
diagnostics/Scre children and cohort studies,
ening adults in case-control
strategies) healthcare studies, cross-
settings sectional studies,
and case series
Q2 Norovirus transmission all type of surfaces, all types of
Gastroenteri pathways patients/partic droplet, and observational
tis ipants oral faecal studies -prospective
including route and retrospective
children and cohort studies,
adults in case-control
healthcare studies, cross-
settings sectional studies,
and case series
Review Population Intervention Comparator Outcomes Study Designs
question
Q3 all type of Disinfection Other Severity of RCTs, cluster RCTs,
patients/part /Bleach infection, non-randomised
icipants hand washing/ alcohol based number of controlled trials
including soap/water people (Non-RCTs),
children and Personal infected, controlled before
adults in Protective duration of and after studies
healthcare Equipment etc outbreak and interrupted
settings time series studies
(ITS), cohort
studies, case-
control studies,
cross-sectional
studies
Results
Review questions 1 and 2
The literature search identified 1172 abstracts and a further 11 papers were identified through other
sources including reference lists and grey literature searching. After removing 493 duplicates, 690
abstracts were screened for inclusion of the review and 643 abstracts were found not relevant to the
study purpose. Application of the inclusion/exclusion criteria resulted in the further exclusion of 14
full text papers leaving 33 studies for the review question 1 and 2. Figure 1 illustrates the study
selection process.

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PRISMA Flow Diagram
Records identified through Additional records identified

database searching through other sources
(n =1172) (n = 11)
Duplicates removed
(n =493 )
Records screened Records excluded

(n = 690) (n = 643)
Full-text articles assessed Full-text articles excluded,

for eligibility with reasons
(n =47) (n = 14)
Studies included in the

review (Q 1 & Q2)
(n =33)
Figure 1. The study selection process

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Characteristics of included studies

In this literature review, review questions 1 and 2 considered all types of observational studies
including prospective and retrospective cohort studies, case-control studies, cross-sectional studies,
and case series that address one or more of the areas of interest; current epidemiology and
transmission pathways. The review questions 1 and 2 included 33 observational studies which were
Level III and IV with moderate quality. This review included 14 cohort studies, 1 Observational
comparative study, 2 case control studies, 5 case series 11 cross sectional studies. Observational
studies are considered as appropriate study designs to address issues regarding prevalence and
incidence (JBI 2014). A detailed description of included studies and the methodological quality are
presented in the Table 1.
Table 1 Included studies and the methodological quality
Reference Study design Level of Evidence1 Methodological

quality2 Yes/Overall
(Beersma et al. 2009) Retrospective analysis Level IV 7/9
(Cheng, FWT et al. 2006) Case series Level IV 4/9
(Cheng, VCC et al. 2011) Observational comparative study Level III-2 8/9
(Costantini et al. 2016) Prospective cohort study Level III-2 8/9
(Cummins & Ready 2016) Prospective cohort study Level III-2 4/9
(Danial et al. 2011) Prospective cohort study Level III-2 7/9
(Franck et al. 2014) Retrospective cohort study Level III-2 8/9
(Franck et al. 2015) Retrospective cohort study Level III-2 9/9
(Godoy et al. 2015) Descriptive Epidemiological study Level IV 8/9
(Harris et al. 2014) Retrospective Record Analysis Level IV 6/9
(Harris et al. 2013) Prospective cohort study Level III-2 8/9
(Heijne et al. 2012) Cross sectional study Level IV 6/9
(Hoffmann et al. 2013) Cross sectional study Level IV 8/9
(Johnston et al. 2007) Case series Level IV 8/9
(Kanerva et al. 2009) Cross sectional study Level IV 8/9
(Lopman et al. 2006) Prospective cohort study Level III-2 6/9
(Mattner, Guyot & Henke- Retrospective analysis Level IV 8/9
Gendo 2015)
(Munir et al. 2014) Prospective cohort study Level III-2 8/9
(Nenonen et al. 2014) Case control study Level III-2 7/9
(Nguyen & Middaugh 2012) Descriptive epidemiological study Level IV 8/9
(Ohwaki et al. 2009) Retrospective cohort study Level III-2 9/9
(Partridge et al. 2012) Retrospective cohort study Level III-2 8/9
(Rao et al. 2009) Cross sectionals study Level IV 8/9
(Rosenthal et al. 2011) Retrospective chart review Level IV 8/9
(Schmid et al. 2011) Retrospective cohort Level III-2 8/9
(Sheahan et al. 2015) Case series Level III-3 5/9
(Simon et al. 2006) Case series Level III-3 8/9
(Sukhrie et al. 2011) Case control study Level III-2 6/9
(Sukhrie et al. 2012) Retrospective cohort study Level III-2 9/9
(Tsang et al. 2008) Retrospective cohort study Level III-2 9/9
(Tseng et al. 2011) Retrospective cohort study Level III-2 8/9
(Tu et al. 2008) Cross sectionals study Level IV 6/9
(Zheng et al. 2015) Case series Level III-3 6/9
1 2
NHMRC Level of Evidence (NHMRC 2000) The Joanna Briggs Institute Reviewers’ Manual 2014 -The
Systematic Review of Prevalence and Incidence Data (JBI 2014)

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Healthcare settings
This review considered all type of patients/participants including children and adults in healthcare
settings. The health care settings of interest for this review include acute care, aged care, paediatric,
neonatal and rehabilitation. The majority of studies were conducted in USA (7) followed by UK (6),
Netherlands (4), Hong Kong (3), Germany (3), Denmark (2) and individual studies from 8 countries
including Australia. This review involved 28 hospitals and 5 aged care facilities. Included studies
ranged from 1992 to 2015. Table 2 provides details of healthcare settings, participants and study
duration.
Table 2. Details of healthcare settings, participants and study duration
Reference Healthcare setting Participants Study duration

/Country
(Beersma et al. 2009) A tertiary care hospital Hospitalised children 03/2002 to 07/2006
Netherlands and adults
(Cheng, FWT et al. 2006) Public Hospital Children, visitors 19 and 28 August (Year
Hong Kong medical students Not available)
(Cheng, VCC et al. 2011) Public Hospital Hospitalised children 11/ 2009 to 2/2010
Hong Kong
(Costantini et al. 2016) Long-term care facilities (LTCFs) Adults and older adults 11/ 2009 to 01/2013
USA
(Cummins & Ready 2016) Hospitals (coded A–E). London, Hospitalised patients 02 -04 / 2015
UK and staff
(Danial et al. 2011) Hospitals in NHS Lothian, Hospitalised patients 09/ 2007 to 06/ 2009
UK
(Franck et al. 2014) Hospitals Hospitalised patients 2006–2010
Denmark
(Franck et al. 2015) Hospitals Hospitalised patients 2002-2010
Denmark
(Godoy et al. 2015) Hospitals and nursing homes Hospitalised patients 01/ 2010 -12/2011
Spain
(Harris et al. 2014) NHS Hospitals Hospitalised patients 1992–2011
UK
(Harris et al. 2013) NHS Hospitals Hospitalised patients 11/ 2009 -11/2011
UK
(Heijne et al. 2012) Psychiatric wards Patients with mental 2008
Netherlands health conditions
(Hoffmann et al. 2013) University hospital, Munich, Patients and staff 06/2011
Germany
(Johnston et al. 2007) Hospital (JHH) Baltimore, Patients and staff 01-05/2004
USA
(Kanerva et al. 2009) Tertiary care hospital Patients and staff 12/2006 -05/ 2007
Finland
(Lopman et al. 2006) Hospitals Hospitalised patients 04/ 2002- 03/2003
UK
(Mattner, Guyot & Henke- University and teaching hospitals Hospitalised patients 2002-2012
Gendo 2015) Germany
(Munir et al. 2014) Paediatric hospitals in Atlanta Hospitalised children 2009-2010
USA
(Nenonen et al. 2014) University Hospital Hospitalised patients 01-05/ 2012
Sweden
(Nguyen & Middaugh 2012) Long-term care facilities Older residents 02-03/ 2010
USA
(Ohwaki et al. 2009) Hospital and attached LTCF Adults and older 02-03/ 2007
Japan residents
(Partridge et al. 2012) A teaching hospital Hospitalised Adults and 2009-2010
UK older adults
(Rao et al. 2009) Tertiary care facility & LTCF Hospitalised Adults and 2007

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USA older adults

Reference Healthcare setting Participants Study duration
/Country
(Rosenthal et al. 2011) Long-term care facilities (LTCFs), Older residents 2003-2006
USA
(Schmid et al. 2011) 600-bed Hospital, Hospitalised Adults and 03/ 2009
Austria older adults
(Sheahan et al. 2015) Inpatient paediatric unit of Hospitalised children 01-02/2014
tertiary care hospital
USA
(Simon et al. 2006) Paediatric oncology unit, Hospitalised children 01-02/2004
Germany with cancer
(Sukhrie et al. 2011) Tertiary care Hospital Hospitalised patients 2002-2007
Netherlands
(Sukhrie et al. 2012) Tertiary care hospital and nursing Hospitalised Adults and 01/ 2009 -03/ 2010
homes older adults
Netherlands
(Tsang et al. 2008) Public hospitals Hospitalised older 05-07/2006
Hong Kong adults
(Tseng et al. 2011) Psychiatric Unit 01/ 2005 -04/2007
Taiwan.
(Tu et al. 2008) Aged-care facility Older residents 06/ 2003
Australia
(Zheng et al. 2015) Aged care facility Older residents 12/ 2012.
China
Q 1: Epidemiology for Norovirus Gastroenteritis in healthcare

settings
Norovirus detection methods
Noroviruses (NoV) belong to the family Caliciviridae and NoV are a single-stranded RNA, non-
enveloped viruses that cause acute gastroenteritis in humans (Costantini et al. 2016; Siqueira et al.
2016). Noroviruses are divided into at least 6 genogroups (GI-GVI) and further subdivided into more
than 38 genotypes based on phylogenetic analysis of the major capsid protein (Costantini et al. 2016;
Franck et al. 2015). Currently, human noroviruses belong to one of three norovirus genogroups (GI,
GII, or GIV), which are further divided into more than 25 genetic clusters (de Graaf, van Beek &
Koopmans 2016).
Human noroviruses cannot be grown in cell culture (Vinje 2015), therefore, diagnostic methods
focus on detecting viral RNA or antigen. Since the cloning of Norwalk virus in 1990, reverse
transcription-polymerase chain reaction (RT-PCR) assays have been developed for detection of NoVs
in clinical and environmental specimens, such as water and food, however RT-PCR was rapidly
replaced by second-generation assays that proved to be more broadly reactive and able to detect
the majority of the circulating norovirus strains (Pang & Lee 2015). Except one study, all other 32
observational studies used real-time RT-PCR to detect the NoV and some studies used ELISA in
addition to real-time RT-PCR. Until norovirus diagnostic tests become widely available, the Kaplan
criteria (Kaplan et al. 1982) was widely used in healthcare setting as a diagnostic tool to identify
noroviruses outbreaks, and subsequent studies also showed that this set of criteria is highly specific
(99%) with moderate sensitivity (68%) (Turcios et al. 2006). In this review, two studies used Kaplan

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criteria for the identification of norovirus-associated outbreaks (Nguyen & Middaugh 2012; Tsang et
al. 2008), however only one study reported details of the NoV detection using the Kaplan criteria
and the study reported that many cases did not comply with these criteria (Tsang et al. 2008). Table
3 provides details of Norovirus detection methods, prevalence of NoV outbreaks and other screening
method utilised for NoV detection.
Table 3. Details of Norovirus detection methods, prevalence of NoV outbreaks and other screening
method
Reference Norovirus Outbreaks/NoV detection/ Screening methods

detection Participants
methods
(Beersma et al. 2009) Real-time RT- PCR 221 (9.0%) of 2458 hospital patients Not reported
with diarrhoea tested positive for
NoV
(Cheng, FWT et al. Real-time RT-PCR 9 children , 1 visitor, and 1 medical Not reported
2006) student affected
(Cheng, VCC et al. 2011) Real-time RT-PCR 242 (25%) were positive for Not reported
norovirus; 114 (47%) of those 242
patients had norovirus detected by
added test.
(Costantini et al. 2016) Real-time RT-qPCR 10 Outbreaks /39 Not reported
(62 patients)
(Cummins & Ready Real-time RT-PCR 57 Patients/7 Staff from 4 Hospitals Not reported
2016)
(Danial et al. 2011) Real-time RT-PCR 192 unit outbreaks /Norovirus was Not reported
confirmed as
the aetiological agent by PCR in 142
(82%) outbreaks
(Franck et al. 2014) Real-time RT-PCR 46 suspected foodborne outbreaks/ Not reported
an association between infection
with
GII.4 and increasing age
(Franck et al. 2015) Real-time RT-PCR 3656 NoV-infected patients Not reported
(Godoy et al. 2015) Real-time RT-PCR 358 patients and the Not reported
results were positive for norovirus in
45%.
(Harris et al. 2014) Polymerase chain Norovirus was laboratory confirmed Not reported
reaction (PCR) in 69% (2737) of the reported
outbreaks
(Harris et al. 2013) Polymerase chain 65 outbreaks Not reported
reaction (PCR)
(Heijne et al. 2012) No data for 46 patients Not reported
diagnostic
(Hoffmann et al. 2013) Real-time RT-PCR 116 patients; 28 staff Not reported
(Johnston et al. 2007) Real-time RT-PCR 265 staff; 90 inpatients Not reported
(Kanerva et al. 2009) Real-time RT-PCR 502stools specimens Not reported
were tested for norovirus RNA, 181
(36%) - positive
(Lopman et al. 2006) RT-PCR and/or 76 outbreaks/ one or more specimen Not reported
ELISA was positive for norovirus by RT-PCR
[26] and/or ELISA [27] in 76 (63%)
outbreaks
(Mattner, Guyot & RT-PCR and/or Majority of outbreaks occurring on Not reported
Henke-Gendo 2015) ELISA medical wards [medicine 42 (59%),
surgery 12 (17%), neurology 4 (6%),
urology 2 (3%), obstetrics 1 (1%),
psychiatry 3 (4%), combined
medicine/surgery 3 (4%), paediatrics

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1 (1%) and dermatology 1 (1%)].

Reference Norovirus Outbreaks/NoV detection/ Screening methods
detection Participants
methods
(Munir et al. 2014) Real-Time RT-PCR NoV was identified in 16.3% (15/92) Not reported
of all stool specimens; 23.4% (11/47
immunocompromised children
(Nenonen et al. 2014) RT-PCR (rRT-PCR) NoV GII was detected in 48 of 101 Not reported
(47%) environmental swabs and 63 of
108 patients
(58%);
(Nguyen & Middaugh RT-PCR (rRT-PCR) Older residents /32 stool specimens Patients who did not meet
2012) were positive for norovirus the Kaplan criteria were also
tested using RT-PCR- No
further details provided
(Ohwaki et al. 2009) Real-Time RT-PCR older residents/ 23 out of 32 stool Not reported
samples were positive for NoV
(Partridge et al. 2012) Real-Time RT-PCR 623 hospitalised Adults and older Not reported
adults positive for NoV
(Rao et al. 2009) NA Survey of hospitalised Adults and Not reported
older adults
(Rosenthal et al. 2011) Real-Time RT-PCR Older residents-163/234 (70%) Not reported
Outbreaks
(Schmid et al. 2011) Real-Time RT-PCR 17/204 positive for NoV Not reported
(Sheahan et al. 2015) Real-Time RT-PCR 14 Hospitalised children Automated hourly NV
diagnostic testing report
Screening (using xTAG GPP)
on stool samples
(Simon et al. 2006) RT-PCR and/or 21/ 246Hospitalised children with Not reported
ELISA cancer positive for NoV
(Sukhrie et al. 2011) Real-Time RT-PCR 264 patients (of 2,458 tested) were Not reported
diagnosed with NoV infection during
the 5-year period
(Sukhrie et al. 2012) polymerase chain Five outbreaks were investigated, Not reported
reaction (PCR) involving 28 patients with recognized
symptomatic NoV infection
(Tsang et al. 2008) Real-Time RT-PCR 151 (72.6%) samples were NoV Kaplan’s criteria used
positive. The median age of our for the identification of
patients was 74.5 years norovirus-associated out-
breaks. Many cases did not
comply with these criteria.
Only 46.3% of patients had
vomiting and the median
duration of diarrhoea in the
cohort was 3 days with a
range of 1-24 days instead of
12-60 hrs. The duration of
symptoms may indeed last
longer than previously
recognised
(Tseng et al. 2011) ELISA method and 4 norovirus outbreaks occurred Not reported
RT–PCR within this psychiatric unit (172)
(Tu et al. 2008) Real-Time RT-PCR 14 Older residents positive for NoV Not reported
(Zheng et al. 2015) Real-Time RT-PCR RT-PCR revealed that 39 samples Not reported
were
norovirus-positive

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Prevalence of Norovirus Geno-groups

In this review, 21 observational studies reported the prevalence of NoV genogroups and 17 studies
(81%) identified that NoV genotype GII.4 have caused the majority of clinical outbreaks in healthcare
settings during the past decade. Nine observational studies involving 4 long-term aged care facilities
(Costantini et al. 2016; Nguyen & Middaugh 2012; Rosenthal et al. 2011; Zheng et al. 2015), 2 aged
care facilities attached to the major hospitals (Godoy et al. 2015; Ohwaki et al. 2009) and 3 public
hospitals (Franck et al. 2014; Franck et al. 2015; Tsang et al. 2008), revealed NoV GII.4 predominated
in older adults. Franck et al. (2014) conducted a Cohort study involving 3,846 patients who were
positive for NoV by routine diagnostic procedures for gastroenteritis in Denmark during 2006–2010,
the study detected an association between an age ≥60 years and infection with NoV GII.4 in patients
from community and health care settings. Table 4 provides details of NoV Genogroups prevalence in
healthcare settings.
Table 4. Details of Norovirus Genogroups prevalence in healthcare settings
Reference Healthcare Outbreaks/NoV Norovirus genogroups

setting/Participants detection/
Participants
(Costantini et al. 2016) Long-term care facilities 10 Outbreaks /39 GII.4 Sydney outbreaks was
(LTCFs) (62 patients) significantly higher than in
Adults and older adults outbreaks caused by other
genotypes
(Nguyen & Middaugh Long-term care facilities Older residents /32 stool Sequenced specimens were
2012) Older adults specimens were positive for closely related to GII.4 New
norovirus Orleans
(Rosenthal et al. 2011) Long-term care facilities Older residents-163/234 Overall, strains belonging to eight
(LTCFs), (70%) Outbreaks NoV genotypes (GI.1, GI.4, GI.6,
Older Adults GII.3, GII.4, GII.5, GII.6, GII.10)
were detected in LTCFs during the
study period. GII.4 strains
accounted for 108 (84%)
(Zheng et al. 2015) Long-term care facilities RT-PCR revealed that 39 Epidemiological Investigation of a
Older Adults samples were Norovirus GII.4 Sydney Outbreak
norovirus-positive
(Godoy et al. 2015) Hospitals and attached 358 patients and the results GII.4 was detected in 66·7%
nursing homes were positive for norovirus (10/15) of outbreaks.
Hospitalised adults and in 45%.
older adults patients
(Ohwaki et al. 2009) Hospital and attached older residents/ 23 out of 32 NoV GII/4 detected in23/32
LTCF stool samples were positive samples
Adults and older for NoV
residents
(Franck et al. 2014) Hospitals 46 suspected foodborne /strong association between
Hospitalised patients outbreaks/ 3,846 NoV infection with NoV GII.4 and
Positive patient age ≥60 years in
community and health care
settings
(Franck et al. 2015) Hospitals 3656 NoV-infected patients Nosocomial infection
Hospitalised adults and was mainly associated with older
older patients age but also with the specific
genotype GII.4.
(Tsang et al. 2008) Public hospitals 151 (72.6%) samples were New strains of genotype
Hospitalised older adults NoV positive. The median II.4 emerged
age of our patients was 74.5

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years
Section 2
(Beersma et al. 2009) A tertiary care hospital 221 (9.0%) of 2458 hospital GIIb strains occurred mainly in
Hospitalised children patients with diarrhoea children below the age of two-
and adults tested positive for NoV and-a-half years [odds ratio (OR):
14.7; P<0.0001] GII.4 strains
affected all age groups
(Cheng, VCC et al. Public Hospital 242 (25%) were positive for Forty-three (93%) of 46 norovirus
2011) Hospitalised children norovirus; 114 (47%) of isolates sequenced belonged to
those 242 patients had the G II.4 variant
norovirus detected by added
test.
(Cummins & Ready Hospitals (coded A–E 57 Patients/7 Staff from 4 GII was the dominant genogroup
2016) Hospitalised patients Hospitals detected and comprised
and staff 94.6% of all the norovirus-positive
samples
(Hoffmann et al. 2013) University hospital, 116 patients Novel strain classified as
Munich 28 staff GII.g/GII.1 - causative agent for an
Patients and staff extended outbreak.
(Johnston et al. 2007) Hospital 265 staff Detected noroviruses had 98%–
Patients and staff 90 inpatients 99% sequence identity with
representatives
of a new genogroup II.4 variant
(Kanerva et al. 2009) Tertiary care hospital 502stools specimens Three main GII.4-2006b
Patients and staff were tested for norovirus subvariants entered the hospital
RNA, 181 (36%) - positive with gastroenteritis patients
(Lopman et al. 2006) Hospitals 76 outbreaks/ one or more 95% closely clustered with
Hospitalised patients specimen was positive for genogroup II4
norovirus by RT-PCR [26]
and/or ELISA [27] in 76
(63%) outbreaks
(Munir et al. 2014) Paediatric hospitals NoV was identified in 16.3% All NoV positive cases were
Hospitalised children (15/92) of all stool genogroup II (GII), and GII.4 was
specimens; 23.4% (11/47 the predominant strain followed
immunocompromised by GII.3, GII.12, and GII.13
children
(Nenonen et al. 2014) University Hospital NoV GII was detected in 48 NoV genotype II.4 was sequenced
Hospitalised patients of 101 (47%) environmental from 18 environmental samples,
swabs and 63 of 108 dust (n=8), virus traps (n=4),
patients surfaces (n=6), and
(58%); 56 patients. In contrast, NoV GII
was detected in 2 (GII.4) of 28
(7%) environmental samples and
in 2 (GII.6 and GII.4) of 17 patients
in the outbreak-free ward.
Sequence analyses revealed a high
degree of similarity (>99.5%, 1,040
nt) between NoV
GII.4environmental and patient
strains from a given ward at a
given time.
(Sukhrie et al. 2011) Tertiary care Hospital 264 patients (of 2,458 51% (n= 82) belonged to GII.4,
Hospitalised patients tested) were diagnosed with 34% (n= 54) belonged to GII.3, and
NoV infection during the 5- 15% (n=24) belonged to other
year period genotypes (GI.6B, GII.17, GII.7,
and GII.2). In children’s wards,
GII.3 strains were associated with
nosocomial spread
(Sukhrie et al. 2012) Tertiary care hospital Five outbreaks were NoV genotypes (ie, GII.4, GII.2,
and nursing homes investigated, involving 28 and GII.7).

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Hospitalised Adults and patients with recognized

older adults symptomatic NoV infection
(Tu et al. 2008) Aged-care facility 14 Older residents positive Norovirus genogroup II excretion
Older residents for NoV during an outbreak of
gastroenteritis was investigated in
an aged-care facility.
Clinical features of norovirus gastroenteritis in outbreaks

Norovirus infections generally have a shorter incubation period and are characterized by acute onset
of nausea, vomiting, abdominal pain and diarrhoea (Cheng, VCC et al. 2011; Cummins & Ready
2016). This review identified 10 observational studies that provided clinical features of patients with
norovirus gastroenteritis in outbreaks. The review found that the prevalence of diarrhoea (range:
61%-97%) and vomiting (range: 46%-98%) was higher in adults and older adults, whereas the
prevalence of vomiting (82%) was higher in children. The mean duration of symptoms is 2-3 days.
Table 5 provides details of clinical features, symptom duration and populations of included 11
observational studies.
Table 5. Details of clinical features, symptom duration and populations
Reference Clinical features Duration Population

(Cheng, FWT et al. Vomiting (82%) The median duration of Mostly children
2006) Diarrhoea (63%) Gastroenteritis was three days
Fever (18%) (range: 2-6 days).
(Costantini et al. 2016) Diarrhoea (84%), Illness duration was longer in cases Mostly older adults
fatigue (81%), aged ≥70 years (n = 29;
vomiting (76%), median, 4; interquartile range
nausea (74%). [IQR], 3–4) than aged <70 years(P =
Presence of both .041), with 19 (60%) lasting >3 days
vomiting and and 4 (13%) lasting >5 days
diarrhoea (62%)
(Godoy et al. 2015) Diarrhoea (61·5%) The mean duration of symptoms Mostly older adults
Vomiting (55·0%) was 2·24 (S.D.=1·5) days and was
Abdominal pain greater in hospital patients
(34·9%), nausea (2·56, S.D.=1·7) than in nursing
(33·8%) and fever home residents (2·05, S.D.=1·4)
(20·2%) (P<0·001).
(Johnston et al. 2007) Nearly 50% of HCWs Symptoms lasted for a mean On average, HCWs were
reported fever duration (±SD) of 3.2±1.4 days and younger than patients, with
(42.2%), chills 3.7±3.2 days for HCWs and mean ages (±SD) of
(59.2%), or myalgia patients, respectively 36.2±10.4 years and
(55.7%). Thirteen 45.5±23.4 years, respectively
(4.9%) of the 265
HCWs required
emergency
department visits
(n=9) or
hospitalization (n=4)
for intravenous
hydration
(Nguyen & Middaugh Of 207 cases, 176 No details Mostly older adults
2012) (85%, range 68–
100%) experienced
diarrhoea and 98
(47%, range 19–64%)
vomiting
(Ohwaki et al. 2009) Staff members (285) No details Mostly adults (staff) older
Diarrhoea (72%), adults (patients)

P a g e | 15
Vomiting (57%) and

fever (57%)
Reference Clinical features Duration Population

(Rao et al. 2009) 93 (91%) experienced The median number of days ill was Adult staff members
at least 2 episodes of 3 (range, 0.25–14 days; mean, 3.5
vomiting, and 71 days
(70%) had at least 3
episodes of
diarrhoea).
(Tsang et al. 2008) Diarrhoea 97.2% The median duration for diarrhoea Mostly older adults
Vomiting - 46.3% was 3 days and the longest 24 days.
The median duration of vomiting
was one day and the longest 15
days. Fever occurred in one-third of
all cases
(Tseng et al. 2011) Diarrhoea (87.5%), The mean duration of all 184 Mostly adults
Vomiting (25.5%), affected patients was
Abdominal pain 2.1±1.5 days. Most patients
(4.9%) and fever (159/184, 86.4%) experienced
(2.2%) illness for 1–3 days
(Tu et al. 2008) Vomiting (78.6% symptoms lasted on average 2.6 Mostly older adults
Diarrhoea (71.4%), days (range, 1 to 4
Nausea (50.0%) days; median, 3 days)
Abdominal cramps
(35.7%)
(Zheng et al. 2015) Abd pain (86.5%), The disease remitted within 2-3 Mostly older adults
Diarrhoea (67.6%), days
Vomiting (45.9%).
Q 2: Transmission pathways for Norovirus Gastroenteritis in

healthcare settings
Transmission pathways
Faecal-oral pathway is generally the most prominent mode of transmission for norovirus infections.
This review found that transmission for NoV infections in healthcare setting mainly occurs by the
faecal–oral route, either through person to person contact or through exposure to contaminated
food. Table 6 shows the details of NoV transmission pathways based on available data from 9
observational studies. Two studies assumed that NoV infection was hospital-acquired if there was an
interval of at least five days between hospital admission and initial diagnostic sampling (Beersma et
al. 2009; Franck et al. 2015). Determination of transmission pathways are varied and details are
provided in Table 6.
In addition five observational studies suggested that there is a possibility of viral transmission via
aerosols that were likely to be generated during severe vomiting. Table 7 shows summary of viral
transmission via aerosols, although there is no data or determination criteria provided to support
this assumption except one study which detected airborne dispersal of NoV in dust particles
(Nenonen et al. 2014)
It appears that genotype GII.4 is more often associated with transmission mediated by person-
to‑person contact than with other types of transmission.

P a g e | 16
Table 6. Details of NoV major transmission pathways
Reference Transmission pathways Transmission Norovirus genogroups

/Healthcare determined criteria
setting /Country
(Beersma et al. 2009) Among 197 patients who were It was assumed that NoV GIIb strains occurred mainly
A tertiary care in hospital at the time of infection was hospital- in children below the age of
hospital Netherlands diagnosis, NoV was acquired acquired if there was an two-and-a-half years [odds
nosocomially in 113 (57.4%). interval of at least five days ratio (OR): 14.7; P<0.0001]
The proportion of NoV between hospital admission GII.4 strains affected all age
infection that was and initial diagnostic groups
nosocomially acquired was sampling. This assumption
highest in the youngest was confirmed by
patients (58%) and in the analysing the clinical
elderly (78%) symptoms at admission
(Franck et al. 2014) 157 (2109) admitted to A genotype based on Healthcare setting GII.4
Hospitals hospital - foodborne outbreaks sequence information from (91%),
Denmark (community)/ the polymerase and the children <3 years of age
Nosocomially infected patients capsid genes was obtained infected with NoV GII.3 or
(n = 539) for NoVs in 349 (17%) GII.P21 ranged from 11% to
samples. No further details 25%
available
(Franck et al. 2015) 64% of the patients (range, NoV infections were GII.4 infections were also
Hospitals 37%– classified as community associated
Denmark 87%) had nosocomial NoV acquired if stools were with nosocomial NoV
infections. Nosocomial sampled on the day of infections
Infections among inpatients admission (day 0) or the
(≥60 years) (67%), children and following day (day 1) and
adolescents (age, <18 years). nosocomial if sampling was
(28%) performed on day 5 or
later.
(Godoy et al. 2015) Person-to-person transmission The mechanism of GII.4 was detected in 66·7%
Hospitals and nursing 81·5% (22/27) of NoV transmission was (10/15) of outbreaks.
homes Spain confirmed outbreaks. determined through
Foodborne and person-to- microbiological and
person transmission -11·1% statistical analysis for all
(3/27) and Foodborne 7·4% outbreaks by
(2/27). epidemiologists.
(Heijne et al. 2012) Patient to patient (64%), The construction of No details
Psychiatric wards Patient to healthcare worker transmission trees- (1)
Netherlands (29%) constructed a transmission
matrix by calculating serial
intervals (the duration in
days between the dates
of symptom onset) for any
pair of cases. (2) this
transmission matrix is
translated into a
transmission tree.
(Kanerva et al. 2009) NoV confirmed cases, 121 A detailed sequence Three main GII.4-2006b
Tertiary care hospital (67%) were nosocomial comparison of viruses in a subvariants entered the
Finland random sample of hospital with gastroenteritis
microbiologically verified patients,
norovirus patients in the
most heavily affected

P a g e | 17
wards enabled an
estimation of local virus
transmission.
Reference Transmission pathways Transmission Norovirus genogroups
/Healthcare determined criteria
setting /Country
(Mattner, Guyot & NoV nosocomial acquisition Patients who became No details
Henke-Gendo 2015) confirmed in 30 (68%) symptomatic more
University and outbreaks than 48 h after admission
teaching hospitals were defined as having
Germany nosocomially acquired
disease.
(Ohwaki et al. 2009) Main mode of transmission: Observations suggested NoV GII/4 detected in23/32
Hospital and attached foodborne that lunch on 20 Feb- was samples
LTCF the potential source of the
Japan outbreak. Standard diet
may have been
contaminated while being
prepared in the central
kitchen
(Rosenthal et al. 2011) All confirmed NoV outbreaks, If a point source of GII.4 strains accounted for
Long-term care primary transmission mode infection is suggested 108 (84%)
facilities (LTCFs), USA was - person-to-person (94%), by the epidemic curve and
foodborne (2.5%) and other epidemiological
undetermined for 3.5%. evidence, an investigation
of the source of exposure
was conducted. No further
details available
Table 7. Summary of viral transmission via aerosols
Reference /Healthcare setting Summary of possible aerosol transmission

/Country
(Cheng, FWT et al. 2006) The study recommended surgical masks for staff in the ward areas in
Public Hospital, Hong Kong order to minimize the possibility of viral transmission via aerosols that
were likely to be generated during severe vomiting.
(Harris et al. 2013) Vomiting and the resultant aerosols are important in transmitting the
NHS Hospital, UK Infection. People exposed to vomiting events, either by being close to
the person who initially vomited, or by occupying the same area
sometime after the initial event, have a higher infection risk
(Lopman et al. 2006) During vomiting virus is aerosolised. It can then be transmitted directly
NHS Hospital, UK through the air or can settle and contaminate the surrounding
environment or foodstuffs, later to be inadvertently swallowed.
(Nguyen & Middaugh 2012) NoV-containing faecal matter or aerosolized vomitus, or by indirect
Long Term Care Facilities, USA contact with these via environmental surfaces may have spread the
virus to other residents and staff in the course of their work
(Nenonen et al. 2014) NoV genotype II.4 was sequenced from 18 environmental samples, dust
University Hospital (n=8), virus traps (n=4), surfaces (n=6), and 56 patients. Airborne
Sweden dispersal of NoV detected in dust particles and in Virus tap samples from
patient rooms, may be a source of contamination in nosocomial
outbreaks.
NoV Shedding in healthcare settings

Based on four observational studies individuals may shed NoVs more than 21 days after the
resolution of symptoms, possibly acting as a possible source for nosocomial transmission. However
no data has been reported on ongoing transmission or secondary cases. The age group of included 4

P a g e | 18
studies consisted of children and older adults and prolonged viral shedding has been reported in
paediatric oncology patients infected with NoV (median 23 days; range 3-140 days). Table 8 shows
the details of NoV shedding and NoV genogroups associated with virus transmission.
Table 8. Details of NoV shedding and NoV genogroups associated with virus transmission.
Reference Population Virus shedding Norovirus genogroups/

/Healthcare Ongoing
setting /Country Transmissions/
Secondary cases
(Beersma et al. 2009) Among 197 patients Follow-up samples were obtained GIIb strains occurred mainly
A tertiary care (Children and adults), from 53 of 197 admitted patients in children below the age of
hospital Netherlands NoV was acquired (26.9%). Long-term shedding (more two-and-a-half years [odds
nosocomially in 113 than one month) was demonstrated ratio (OR): 14.7; P<0.0001]
(57.4%). for 12 patients (22.6% of those with GII.4 strains affected all age
adequate follow-up, 6.1% of all groups
admitted NoV patients). Twenty
patients were co-infected with No data available ongoing
rotavirus (n=5 patients) or transmissions or secondary
parechoviruses (n =15); most of these cases
occurred in patients aged <10 years.
Virus shedding may be detected after

discharge
(Costantini et al. 2016) Sixty-two cases (65% Prolonged shedding (≥21 days) was GII.4 Sydney
Long-term care aged ≥70 years), 34 detected in 16 (47%) of the 35 cases
facilities (LTCFs) USA exposed controls (9% with positive acute stool. Spearman No data available ongoing
aged ≥70 years), and correlation was used to compare transmissions or secondary
18 nonexposed illness and shedding duration with cases
controls (5% aged≥70 severity score. Shedding duration
years) were enrolled was analyzed as Kaplan–Meier
survival probability. No associations
between severity of disease, illness
duration, and virus shedding was
found.
Virus shedding may be detected

during the stay -LTCF
(Simon et al. 2006) Stool and vomitus Follow-up investigation No details

Paediatric oncology samples from 11 demonstrated viral shedding for a
unit, Germany Paediatric oncology maximum of 140 days (median 23 No data available ongoing
patients were tested days; range 3-140 days) in 12 transmissions or secondary
for NoV hospitalised children with cancer. cases
Virus shedding may be detected after

discharge
(Tu et al. 2008) 14 volunteers (six The duration of viral shedding: Norovirus GII
Aged-care facility males and eight average 28.7 days (median, 28.5
Australia females) (median, 85 days), with a range of 13.5 to 44.5 No data available ongoing
years), 13 were days transmissions or secondary
patients (aged 63 to cases
93 years) and one Virus shedding may be detected

P a g e | 19
was a staff member during the stay -LTCF

(58 years old)
Results
Q 3: Infection prevention and control strategies

The literature search identified 614 abstracts and a further five papers were identified through other
sources including reference lists and grey literature searching. After removing 155 duplicates, 464
abstracts were screened for inclusion of the review and 449 abstracts were not relevant to the study
purpose. Application of the inclusion/exclusion criteria resulted in the further exclusion of six full
text papers leaving nine (n=9) studies for the review question 3. Figure 1 illustrates the study
selection process.
PRISMA Flow Diagram
Records identified through Additional records identified

database searching through other sources
(n =614) (n = 5)
Duplicates removed
(n =155)
Records screened Records excluded

(n = 464) (n = 449)
Full-text articles assessed Full-text articles excluded,

for eligibility with reasons
(n =15) (n = 6)
Studies included in the

review (Q 3)
(n =9)
Figure 2. The study selection process

P a g e | 20
Characteristics of included studies

To evaluate the effectiveness of transmission based precautions and control strategies, the gold
standard study design is a randomised controlled trial (RCT). However, this literature review failed to
find a RCT or other research designs including cluster RCTs, non-randomised controlled trials (Non-
RCTs), controlled before and after studies and interrupted time series studies (ITS). In the absence of
above research studies, other quantitative research designs were considered. The included nine studies
were observational studies and experimental controlled laboratory designs. Table 6 presents included
studies and the methodological quality.
Table 9. Included studies and the methodological quality
Reference Study design Level of Methodological

Evidence1 quality2 Yes/Overall
(Blaney et al. 2011) A cross-sectional survey Level IV 8/9
(Cheng, VCC et al. 2011) Observational comparative study Level III-2 8/9
(Haill et al. 2012) Prospective Intervention study Level III-2 8/9
(Harris, Adak & O'Brien 2014) Retrospective Record Analysis Level IV 8/9
(Illingworth et al. 2011) Pre and Post Test Design Level III-3 8/9
(Liu et al. 2010) Experimental Controlled Laboratory Design + 5/9
(Morter et al. 2011) Pre and Post Test Design Level III-3 8/9
(Park et al. 2010) Experimental Controlled Laboratory Design + 5/9
(Tung et al. 2013) Experimental Controlled Laboratory Design + 5/9
1
NHMRC Level of Evidence (NHMRC 2000) 2 The Joanna Briggs Institute Reviewers’ Manual 2014 -
The Systematic Review of Prevalence and Incidence Data (JBI 2014) + NHMRC Level of Evidence not
determined
Healthcare settings
This review considered all type of patients/participants including children and adults in healthcare
settings. The health care settings of interest for this review include acute care, aged care, paediatric,
neonatal and rehabilitation. Table 7 provides details of healthcare settings, participants and study
duration.
Table 10. Details of healthcare settings, participants and study duration
Reference Healthcare setting Participants/ NoV Study duration

/Country outbreaks
(Blaney et al. 2011) State health departments in Patients and staff of 2006-2007
Maine, New Hampshire, and LTCFs (survey
Vermont, USA responses)
Confirmed norovirus
outbreaks 29/73
(Cheng, VCC et al. 2011) 6 hospital networks in Hong Kong Hospital staff 2009-2010
Confirmed norovirus
cases 242/988
(Haill et al. 2012) A 1200-bed teaching hospital in 11 and 44 outbreaks 2005-2011
southwest England per year
(Harris, Adak & O'Brien NHS Hospitals, UK 3650 laboratory- 2009-2012
2014) confirmed norovirus
outbreaks
(Illingworth et al. 2011) Lancashire Teaching Hospitals, 67 NoV Outbarks 2007-2010
UK
(Liu et al. 2010) Laboratory setting, USA 10 volunteers human No details
finger pads

P a g e | 21
Reference Healthcare setting Participants/ NoV Study duration

/Country outbreaks
(Morter et al. 2011) 963-bedded teaching NoV was detected in 75 2009-2010 (4 months)
hospital, UK (31.4%) of 239
environmental swabs
(Park et al. 2010) Laboratory setting, USA NA 2009
(Tung et al. 2013) Laboratory setting, USA NA No details
NoV Infection prevention and control strategies in healthcare

settings
The effectiveness of hand sanitizers
The World Health Organization recommends the use of alcohol-based hand sanitizer (ABHS) for hand
hygiene in health care settings when hands are not visibly soiled. Based on the findings of 5 included
studies, no reliable conclusion can be made on the effectiveness of alcohol-based hand sanitizer for
the prevention and control of NoV infection in healthcare settings. According to Park et al. (2010)
90% Ethanol or 90% Isopropanol may be effective against NoV, however it is not clear whether lower
concentrations (50 to 70%) of alcohols, which are widely used in commercial sanitizers, are effective
against human NoV. Table 8 provides study summaries on the effectiveness of hand sanitizers. In
combination with other infection control strategies, alcohol based hand rub may be useful in
controlling nosocomial transmission of norovirus (Cheng, VCC et al. 2011)
Table 11. Effectiveness of hand sanitizers
Reference Intervention/ Results/Outcomes Conclusion

Comparison
(Blaney et al. 2011) Alcohol-based hand In LTCFs with laboratory-confirmed Preferential use of ABHS
sanitizer (ABHS) versus norovirus outbreak, Staff were over soap and water for
A cross-sectional soap and water equally or more likely to use ABHS routine hand hygiene
survey than soap and water for routine might be associated with
91 LTCFs (60%) provided hand hygiene had higher odds of an increased risk of
Level IV survey responses 61 outbreak than facilities with staff norovirus outbreaks in
facilities reporting 73 less likely to use ABHS (adjusted LTCFs.
outbreaks; 29 were odds ratio, 6.06; 95% confidence
confirmed norovirus interval:1.44-33.99 p = .02).
(Cheng, VCC et al. Staff education (N=3594 - Overall rate of hand hygiene Strategic infection
2011) 18 months) and promotion compliance of hospital staff - control measures
of directly observed hand between 60% and 70% after 3 year including staff education
Observational hygiene using alcohol based follow up and observed hand
comparative study hand rub (ethanol (80% During12 months period, the hygiene using alcohol
vol/vol), incidence of hospital-acquired based hand rub with an
Level III-2 242/988 patients were norovirus infection decreased from added test to detect the
positive for norovirus 131 to 16 cases per 1,000 Norovirus may be useful
potentially infectious patient-days in controlling nosocomial
(P< .001) transmission of
norovirus
(Liu et al. 2010) Efficacy of (1) sodium Reduction in genomic copies of NV Ethanol-based hand
Experimental hypochlorite Vs ethanol (2) cDNA with the antibacterial liquid sanitizers are less
controlled laboratory antibacterial liquid soap soap treatment (0.67 to 1.20 log10 effective controlling the
design (Fisher Scientific reduction) and water rinse only transmission of HuNoV
International-Hampton, (0.58 to 1.58 log10 reduction). The group
NH) and alcohol-based alcohol-based hand sanitizer was
hand sanitizer (2% ethyl relatively ineffective, reducing the
alcohol) for the inactivation genomic copies of NV cDNA by only
of Norwalk virus (NV) on 0.14 to 0.34 log10 compared to

P a g e | 22
human finger pads baseline

Comparison
(Park et al. 2010) Virucidal efficacy of seven For GII.4 NoV, 50 and 70% ethanol Significant reduction in
Experimental hand sanitizers containing and isopropanol resulted in 0.0- to RNAtiters of GII.4 NoV
controlled laboratory various active ingredients 0.6-log reductions of viral RNA, after exposure to 90%
design ethanol, triclosan, and whereas both 90% ethanol and ethanol or 90%
chlorhexidine 90% isopropanol significantly isopropanol indicates
GII.4 norovirus, feline reduced GII.4 RNA (P , 0.001) by 1.2 that both alcohols could
calicivirus (FCV), murine and 1.8 log PCR units per ml, be effective against
norovirus (MNV), fecal respectively, after 5 min of HuNoV.
extract exposure
(Tung et al. 2013) Ethanol (50, 70, and 90%), Both HuNoV strains were more Overall, all 3 products
Experimental sodium/hypochlorite (5, 75, resistant to hypochlorite than were are not effective against
controlled laboratory 250, 500, and 1,000 ppm)/a either of the animal surrogates, HuNoV
design quaternary ammonium with the human strains requiring
compound blend (at 0.1x, >_500 ppm of hypochlorite to
1.0x, and 10x achieve statistically significant
concentrations reduction (>_3.0 log) in virus
concentration.
Two norovirus (NoV) All four viruses were resistant to
genogroup II strains (GII.2 inactivation (,0.5-log reduction)
and GII.4) and two using the quaternary ammonium
surrogates (feline calicivirus compound formulation at all
[FCV] and murine norovirus concentrations tested.
[MNV-1]).
The effectiveness of ward or bay closures

In the past, ward closure was considered as a central control measure for managing hospital
outbreaks of norovirus. However, this review found that entire ward closure may not always be
necessary, and that more efficient control may be achieved by the closure of bays. If implemented,
this approach needs to occur promptly and early (within three days of the first case becoming ill) in
an outbreak before extensive transmission has occurred within a clinical area. Table 9 provides the
effectiveness of the ward or bay closures.
Table 12. The effectiveness of ward or bay closures

Comparison
(Haill et al. 2012) 11 - 44 outbreaks per year. Prior to June 2007, 90% of Many norovirus
outbreaks were managed by outbreaks can be
A 1200-bed teaching First, soon after an closure of an entire ward, controlled by
hospital in southwest outbreak had been compared with only 54% from June containment in bays
England identified, symptomatic 2007 onwards. The duration of rather than by entire
patients were cohorted in closure was significantly shorter for ward closures,
Prospective single rooms or bays in an bays compared with entire wards, particularly when this is
Intervention study attempt to contain the both before (3.5 vs 6, P = 0.0327) combined with adequate
Level III-2 outbreak without closing and after (3 vs 5, P < 0.0001) June infection control support
the entire ward. 2007. When considering all
Wards: 14 - 34 outbreaks, there was a significant
Beds per wards reduction in duration of closure
Bays: beds configured in 5- after the change in strategy (6 vs 5,
or 6-bedded bays, at least P = 0.007).
two of which are fitted with
doors.

P a g e | 23
Comparison
(Harris, Adak & 3650 laboratory-confirmed Closing a bay or ward promptly There is no compelling
O'Brien 2014) norovirus outbreaks. (within 3 days of the first case evidence that closing the
occurring) in an outbreak of ward is an effective way
NHS Hospitals, UK Ward or bay closures, norovirus, the duration of the of curtailing an outbreak
specifically, whether outbreak is shorter compared with of norovirus.
Retrospective Record prompt closure of an the outbreaks where closure is not
Analysis affected ward Vs not to prompt.
Level IV close
Wards: 16-28
Beds per wards
Bays: No details
(Illingworth et al. 67 NoV Outbreaks Significant decrease in the ratio of Closure of entire wards
2011) confirmed hospital outbreaks to during norovirus
Closure of affected ward community outbreaks(r = 0.317, P outbreaks is not always
Lancashire Teaching bays (rather than wards), =0.025), the number of days of necessary. The changes
Hospitals, UK installation of bay doors, restricted admissions on hospital implemented at the
Pre and Post Test enhanced cleaning, a rapid wards per outbreak (r = 0.742, P= study hospital resulted in
Design in-house molecular test and 0.041), and the number of hospital a significant reduction in
Level III-3 an enlarged infection bed-days lost per outbreak (r = the number of bed-days
control team 0.344, P< 0.001). However, there lost per outbreak, and
Wards: No detail of number was no significant change in the this, together with a
of bays per wards number of patients affected per reduction in outbreak
Bays: four-bedded bays hospital outbreak (r =1.080, P= frequency, resulted in
(most open plan without 0.517), or the number of hospital considerable cost savings
doors) staff affected per outbreak (r =
0.651, P =0.105).
Environmental cleaning
This review found a Pre and Post-test study which was conducted to assess the efficiency of cleaning
and identify any NoV contamination in the environment (Morter et al. 2011). In this study, NoV was
detected in 75 (31.4%) of 239 environmental swabs collected from sites on five wards and one day
room. The ward environments and clinical equipment were washed using Actichlor solution (Ecolab
Ltd, Leeds, UK). If soiled with blood or body fluids, equipment was cleaned first with water and
detergent, followed by 10 000 ppm Actichlor plus. However the study does not provide
ingredient/composition of Actichlor solution. It is difficult to determine the effectiveness of cleaning
agents. Ward environment and equipment can be considered as NoV reservoirs (Morter et al. 2011).
Table 10 provide the details of the study.
Table 13. Effectiveness of Environmental cleaning

Comparison
(Morter et al. 2011) Time 1: Wards environment NoV contamination was reduced It is difficult to
and clinical equipment on surfaces sampled from 42.1%to determine the
963-bed teaching were washed using 13.2% and from 48.7% to 19.4% on effectiveness of cleaning
hospital., UK Actichlor.. If soiled with K2 and H3 wards agents however ward
blood or body fluids, 45% swabs from soap and alcohol environment and
Pre and Post test equipment was cleaned dispensers, 45.9% from equipment, equipment can be
design first with water and 29.4% within the nurses’ station, considered as NoV
Level III-3 detergent, followed by 10 42.9% at the bedside and 23.6% reservoirs
000 ppm Actichlor plus from furniture, fixtures and fittings
Environmental monitoring were positive for NoV

P a g e | 24
was performed after

cleaning using Cotton-
tipped swabs
Time 2: Re-cleaned and re-
tested
four-month period during
2009-2010
Other infection control strategies

Considering the limited number of comparative observational studies, this review examined 33
observational studies relevant to Question 1 and 2 to identify NoV infection prevention and control
strategies in healthcare settings. Although there is no evaluation data relevant to the effectiveness of
interventions, 24 (73%) studies provide infection control strategies used during the outbreaks and
are summarised in Table 11. In addition, Table 12 provides details of infection control strategies used
during NoV outbreaks.
Table 14. Reported infection prevention and control strategies
Infection control strategies Number of %

times action
undertaken
Early detection
Early detection/ rapid diagnostic testing 4 4.5
Efficient contact tracing of exposed patients 2 2.2
Restriction of movements
Isolation of patients 9 10.1
Cohorting of symptomatic patients 6 6.7
Restricting of staff & patients 5 5.6
Restricting of visitors 4 4.5
Environmental cleaning
concentrated disinfectant (hypochlorite solution 1000 ppm or 7 7.9
above),
Meticulous handling of waste products 5 5.6
Environmental cleaning (not specified) 9 10.1
Intensive environmental cleaning with bleach or chlorine 5 5.6
Enhanced hand hygiene

Hand hygiene ( not specified) 6 6.7
Washing with soap and water 4 4.5
Alcohol hand rubs 2 2.2
Directly observed hand hygiene 1 1.1
Other actions
Standard precautions / personal protective equipment 5 5.6
Staff education 4 4.5
Exclusion of ill staff (2–5 days after symptoms pass) 7 7.9
Ward or Bay close 4 4.5
Total 89 99.8

P a g e | 25
Table 15. Details of infection control strategies used during NoV outbreaks
Reference Healthcare setting Infection control strategies

/Country
(Cheng, FWT et al. Children, visitors medical Strict contact precautions, prompt isolation and cohorting of
2006) students/ Public Hospital symptomatic patients, vigorous environmental cleansing with
Hong Kong concentrated disinfectant (hypochlorite solution 1000 ppm),
meticulous handling of waste products, and efficient contact
tracing of exposed patients, family members, and medical
students.
(Cheng, VCC et al. 2011) Hospitalised children Staff education and promotion of directly observed hand
Public Hospital hygiene, reverse-transcription polymerase chain reaction for
Hong Kong norovirus was performed as an added test by the microbiology
laboratory for all faecal specimens irrespective of the request
for testing. Laboratory-confirmed cases were followed up by
the infection control team for timely intervention.
(Cummins & Ready Hospitalised patients and Control measures included isolation, hand hygiene,
2016) staff Hospitals (coded A–E). environmental cleaning, and rapid diagnostic testing.
London, UK
(Danial et al. 2011) Hospitalised patients The decision to re-open award is made by the infection control
Hospitals in NHS Lothian, team when there have been no new cases for 72 h and there
UK has been no vomiting or diarrhoea for 72 h from the last
uncontained episode, or if the symptomatic patients are
isolated. A terminal deep clean (remove and change all
curtains, remove all bed linen from all beds, decontaminate all
care equipment in line with manufacturers’ instructions, and
thoroughly clean and then decontaminate all surfaces with a
combined detergent/hypochlorite product) is performed
before the ward is re-opened.
Healthcare workers with gastrointestinal symptoms are taken
off duty and advised not to return to work until they have
been symptom-free for 48 h. For the duration of the outbreak,
staff are allocated to care exclusively for either affected cases
or unaffected cases to help prevent spread of the outbreak.
(Franck et al. 2015) Hospitalised patients Increased focus on cleaning procedures along with immediate
Hospitals isolation of patients with suspected infectious gastroenteritis
Denmark may help diminish the number of nosocomial NoV infections.
(Godoy et al. 2015) Hospitalised patients Environmental decontamination with solutions of hypochlorite
Hospitals and nursing at 1000–5000 ppm, the prevention of food contamination, the
homes Spain exclusion of sick workers, the cohorting of infectious patients
and ensuring hand washing or the use of alcoholic solutions
among healthcare workers
(Harris et al. 2014) Hospitalised patients Closing a bay or ward promptly (within 3 days of the first case
NHS Hospitals occurring) in an outbreak of norovirus, the duration of the
UK outbreak is shorter compared with the outbreaks where
closure is not prompt.
(Harris et al. 2013) Hospitalised patients Increasing barriers to movement between bays by closing
NHS Hospitals affected bays promptly would be effective in preventing
UK further spread.
(Heijne et al. 2012) Patients with mental health All social activities were cancelled to limit patient-to-patient
conditions transmission and healthcare workers were instructed to
Psychiatric wards wear gloves to limit health-care-workers-to-patient
Netherlands transmission. Healthcare workers were also instructed to limit
cross-contact between wards
(Hoffmann et al. 2013) Patients and staff Rigorous hygienic measures, including disinfection
University hospital, Munich, procedures and closure of wards helped contain the outbreak
Germany
(Johnston et al. 2007) Patients and staff Hospital Aggressive infection-control measures, including closure of
(JHH) Baltimore, units and thorough disinfection using sodium hypochlorite,

P a g e | 26
USA were required to terminate the outbreak

Reference Healthcare setting Infection control strategies
/Country
(Kanerva et al. 2009) Patients and staff Cohorting and contact isolation, hand hygiene, temporary
Tertiary care hospital closure of the wards, All touch surfaces cleaned with chlorine
Finland disinfectant, Gloves, aprons and
surgical masks were used
(Mattner, Guyot & Hospitalised patients Constant surveillance for new cases of diarrhoea and vomiting
Henke-Gendo 2015) University and teaching and timely adherence to contact precautions for all exposed
hospitals Germany persons is crucial in outbreak control, as is the need
for extended microbiological testing
(Munir et al. 2014) Hospitalised children Rapid NoV detection system, and strict hospital hygiene
Paediatric hospitals in practices.
Atlanta USA
(Nenonen et al. 2014) Hospitalised patients The high nucleotide similarity between the NoV GII.4 strains
University Hospital from patients and their hospital room environment provided
Sweden molecular evidence of GII.4 dispersal in the air and dust;
therefore, environment cleaning is essential
(Nguyen & Middaugh Older residents ill staff excluded from work for 72 h after resolution of
2012) Long-term care facilities symptoms, hand washing with soap and water, and intensive
USA environmental cleaning with bleach or products effective
against feline caliciviruses from an environmental
protection agency-approved list (http://www.epa.gov/
oppad001/list_g_NoV.pdf).
(Ohwaki et al. 2009) Adults and older residents Disinfection of doorknobs and floors by chlorine and monthly
Hospital and attached LTCF collection of stool samples from kitchen workers.
Japan In addition, employees were instructed to stay at home for a
week if they were having symptoms
(Partridge et al. 2012) Hospitalised Adults and Affected patients and their contacts were isolated or cohorted
older adults and clinical areas closed. Briefly, if isolated cases developed
A teaching hospital within a bay then that bay would be
UK closed until 72 h beyond the last loose stool or vomit of any
patient. The bay would then undergo thorough cleaning with
hypochlorite and change of curtains. If more than one bay was
affected within a clinical area, or if staff were affected, the
whole ward would be closed until 72 h beyond last symptoms.
Cohort wards were created on an ad hoc basis to facilitate
cleaning and re-opening of other areas. Twice daily cleaning
with 0.1% hypochlorite was instituted during outbreaks with
particular attention paid to toilets, commodes and frequently
touched areas such as door handles and rails.
(Rao et al. 2009) Hospitalised Adults and Isolation, cancelled congregate activities, and diverted
older adults patients to alternate hospitals. Removed alcohol-based hand
Tertiary care facility & LTCF hygiene products from the facility and encouraged soap and
USA water hand-washing
Environmental services staff used a chlorine-based
disinfectant to clean rooms. Staff not return to work until 48
hours after complete resolution of symptoms.
(Sheahan et al. 2015) Hospitalised children Patients isolation with contact precautions (Gown, Gloves,
Inpatient paediatric unit of soup and water hand washing, daily communication,
tertiary care hospital enhanced cleaning of entire floor twice, staff education,
USA restriction of visitors
(Simon et al. 2006) Hospitalised children with Hand hygiene with a disinfectant until diagnostic assays turn
cancer negative Paediatric oncology patients must be closely
Paediatric oncology unit, monitored -they face a greater risk of NV-related
Germany complications.
(Sukhrie et al. 2012) Hospitalised Adults and Healthcare workers should not resume work until 2–3 days
older adults after clinical recovery/
Tertiary care hospital and
nursing homes
Netherlands
(Tseng et al. 2011) Patients with mental illness Multiple infection-control measures were implemented; A

P a g e | 27
Psychiatric Unit cohort programme, Standard precautions including wearing

Taiwan. gowns, masks, gloves, head caps and shoe caps were
universally implemented when HCWs entered the
contaminated areas. Vomitus and faecal spillage were soaked
with 0.5% (5000 ppm) bleach for at least 30 min and then
flushed into the sanitary sewer.
Hand hygiene practices: wash hands hourly, 75% alcohol
solution for hand washing; alcohol solution was made
available to visitors ; washing of hands with soap,
chlorhexidine, and water after completing work and before
meals.
Environment-cleaning measures: clean and disinfect the beds,
windows, and chairs of their private rooms with 0.05% bleach
daily
Education programme; restrictions placed on visiting staff and
related HCWs to reduce the frequency and number of staff in
daily ward rounds
HCWs were placed on sick leave for at least 72 h after their
last symptoms,
(Zheng et al. 2015) Older residents Isolated the asymptomatic case, and promptly blocked the
Aged care facility cross-transmission between the attendants and the elderly
China and between attendants and other types of workers.
It is necessary to analyze the stool samples from all staff
(symptomatic and asymptomatic) and to pay attention to staff
education on hand washing and disinfecting faeces and
vomitus appropriately.

P a g e | 28
Discussion
The purpose of this literature review was to examine the current epidemiology (Review Question 1)
and latest evidence on transmission pathways (Review Question 2) and infection prevention and
control measures for Norovirus Gastroenteritis (review question 3). This review included 33
observational studies for the Review Question 1 and 2 and nine studies for the Review Question 3.
Due to limited number of comparative observational studies for the Review Question 3, this review
examined 33 observational studies relevant to Question 1 and 2 and identified 24 (73%) studies that
discussed infection control strategies used during the NoV outbreaks in healthcare settings. The
Review Questions 1 and 2 included 33 observational studies (14 cohort studies, one observational
comparative study, two case control studies, five case series and 11 cross sectional studies) which
were Level III and IV with moderate quality. Observational studies are considered as appropriate
study designs to address issues regarding prevalence and incidence (JBI 2014). For the Review
Question 3, the gold standard study design is a randomised controlled trial (RCT), however, this
literature review failed to find a RCT or other research designs including cluster RCTs, non-
randomised controlled trials (Non-RCTs), controlled before and after studies and interrupted time
series studies (ITS). In the absence of above research studies, other quantitative research designs
were considered and Review Question 3 included six observational studies and three experimental
controlled laboratory designs of moderate quality.
Overall, NoV genogroup II are the most common strains reported in most of the outbreaks
worldwide (Ahmed et al. 2014; Cho et al. 2015). In this review, 17 studies (81%) identified that NoV
genotype GII.4 caused the majority of clinical outbreaks in healthcare settings during the past
decade. This finding is consistent with many other studies conducted around the word and norovirus
strains over the years show emergent strains replacing those previously dominant resulting in new
global epidemics (Greig & Lee 2012). Based on nine observational studies conducted in four long-
term aged care facilities, two aged care facilities attached to the major hospitals and in three public
hospitals, it appears that NoV GII.4 predominated in older adults. Franck et al. (2014) conducted a
Cohort study involving 3,846 patients and revealed an association between an age ≥60 years and
infection with NoV GII.4 in patients from community and health care settings. It seems that older
adults are more susceptible to NoV GII.4 infection, which could partly explain why most NoV
infections in health care settings are caused by this genotype.
NoV infection generally has a shorter incubation (24–48 h) and is characterized by acute onset of
nausea, vomiting, abdominal cramps, and non-bloody diarrhoea (Cheng, VCC et al. 2011; Cummins &
Ready 2016). This review identified 10 observational studies that examined clinical features of
patients with norovirus gastroenteritis in outbreaks. The review found that the prevalence of
diarrhoea (range: 61%-97%) and vomiting (range: 46%-98%) was higher in adults and older adults,
whereas the prevalence of vomiting (82%) was higher in children. The mean duration of symptoms is
2-3 days. Careful examination of clinical symptom especially vomiting is very important to determine
the NoV outbreaks as Kaplan et al. (1982) developed criteria to define norovirus outbreaks, including
incubation period of 24-48 h, stool culture negative for bacterial pathogens, vomiting in >50% of
cases and duration of illness lasting for 12-60 h. In this review, two studies used Kaplan criteria for
the identification of norovirus-associated outbreaks (Nguyen & Middaugh 2012; Tsang et al. 2008),
however only one study reported details of the NoV detection using the Kaplan criteria. Except one
study, all other 32 observational studies used real-time RT-PCR to detect the NoV and some studies

P a g e | 29
used ELISA in addition to real-time RT-PCR. In case of the unavailability of a rapid and accurate
diagnostic assay, Kaplan criteria may be useful in determining NoV outbreaks.
Based on available data from nine observational studies (27%), this review identified that
transmission for NoV infections in healthcare setting mainly occur by the faecal–oral route, either
through person to person contact or through exposure to contaminated food. Determination of
transmission pathways are varied and only two studies reported that NoV infection was hospital-
acquired if there was an interval of at least five days between hospital admission and initial
diagnostic sampling (Beersma et al. 2009; Franck et al. 2015). It appears that genotype GII.4 is more
often associated with transmission mediated by person-to‑person contact than with other types of
transmission. Five observational studies suggested that there is a possibility of viral transmission via
aerosols that were likely to be generated during severe vomiting, although there is no data or
determination criteria reported to support this assumption except one study which detected
airborne dispersal of NoV in dust particles (Nenonen et al. 2014). Cheng, et al. (2006) recommended
surgical masks for staff in the ward areas in order to minimize the possibility of viral transmission via
aerosols. Prolonged viral shedding was reported in four observational studies (12%) and patients
may shed NoVs more than 21 days after the resolution of symptoms, possibly acting as a possible
source for nosocomial transmission. However, no data has been reported on ongoing transmission
or secondary cases. NoV shedding is noticeable among children and older adults and prolonged viral
shedding has been reported in paediatric oncology patients infected with NoV (median 23 days;
range 3-140 days) (Simon et al. 2006). Consistent with the above findings, a recent systematic review
found that prolonged viral shedding among both staff and residents mostly related to older age
(Petrignani et al. 2015).
This review examined the NoV infection prevention and control strategies used during NoV
outbreaks in healthcare settings. The review considered the effectiveness of hand sanitizers, the
effectiveness of ward or bay closures and environmental cleaning using nine studies including six
observational studies (Level III- IV) and three experimental controlled laboratory designs. Based on
the findings of five included studies (55.5%), no reliable conclusion can be made on the effectiveness
of alcohol-based hand sanitizer for the prevention and control of NoV infection in healthcare
settings. According to Park et al. (2010), 90% Ethanol or 90% Isopropanol may be effective against
NoV, however it is not clear whether lower concentrations (50 to 70%) of alcohols, which are widely
used in commercial sanitizers, are effective against human NoV. However in combination of other
infection control strategies, alcohol based hand rub may be useful in controlling nosocomial
transmission of norovirus (Cheng et al. 2011). In the past, ward closure was considered as a central
control measure for managing hospital outbreaks of norovirus, however this review found that
entire ward closure may not always be necessary, and that more efficient control may be achieved
by closure of bays. If implemented, this approach needs to occur promptly and early (within three
days of the first case becoming ill) in an outbreak in combination with adequate infection control
strategies. This review found a Pre and Post-test study which was conducted to assess the efficiency
of cleaning using 10 000 ppm Actichlor plus and identify any NoV contamination in the environment,
however it is difficult to determine the effectiveness of Actichlor plus cleaning agents (Morter et al.
2011).
In addition to above nine studies, this review examined 33 observational studies to identify NoV
infection prevention and control strategies in healthcare settings. Although there is no evaluation

P a g e | 30
data relevant to the effectiveness of interventions, 24 (73%) studies provide infection control
strategies used during outbreaks. Early detection and rapid diagnostic testing allowing immediate
implementation of control measures was noted in 4/89 studies (4.5%). The restriction of movements
of patients, staff and visitors is frequently reported as a measure to control the spread of an
outbreak (24/89 studies; (27%). Patient isolation strategies (9/89 studies; 10.1%) may be difficult
due to a lack of isolation rooms, however cohorting of symptomatic patients (6/89; 6.7%) and
restricting of staff, patients, visitors (9/89; 10%) may minimise potential transmissions of NoV.
Environmental cleaning (26/89 studies; 29.2%) was considered as an important intervention for the
prevention and control of NoV infection in healthcare settings. Environmental decontamination with
solutions of hypochlorite at 1000–5000 ppm was suggested (7/89 studies; 7.9%) and intensive
environmental cleaning with bleach or chlorine also suggested in 5/89 studies (5.6%) with particular
attention to frequently touched areas such as toilets and door handles. Following the outbreak, the
ward and used equipment should be thoroughly cleaned using combined detergent/hypochlorite
product and a change of curtains is recommended before the ward is re-opened (Danial et al. 2011;
Partridge et al. 2012).
Hand washing/hygiene (13/89 studies; 14.5%) is considered as the single most effective measure for
preventing infections (Huang, Stewardson & Grayson 2014), however conflicting recommendations
were noted regarding the use of alcohol hand sanitizers. Rao et al. (2009) suggested removing
alcohol-based hand hygiene products from the facility and encouraged soap and water hand-
washing, while Tseng et al. (2011) recommended the use of 75% alcohol solution for hand washing..
The Australian Guidelines for the Prevention and Control of Infection in Healthcare (2010)
recommended that hand hygiene should be performed using soap and water when Clostridium
difficile or non-enveloped viruses such as norovirus (NHMRC 2010) are identified. The increased use
of personal protective equipment incorporated into standard precautions (5/89; 5.6%) and staff
education on infection control strategies (4/89 studies; 4.5%) were frequently reported as control
measures. Exclusion of ill staff for 2–5 days following final symptoms was reported as effective in
controlling transmission of infection (7/89 studies; 7.9%). The Australian Guidelines for the
Prevention and Control of Infection in Healthcare (2010) recommended that healthcare workers
should not return to work until diarrhoea and vomiting have ceased for two days (NHMRC 2010) and
that healthcare workers should comply with appropriate hand hygiene methods and stringent
infection prevention and control practices upon return to work, because of possible prolonged viral
shedding. It can be concluded that a combination of infection control strategies such as early
detection and rapid diagnostic testing, immediate implementation of infection control measures,
including isolation/cohorting of infected patients, hand hygiene, proper environmental cleaning and
staff education can be effective in controlling NoV outbreaks in healthcare settings. However due to
the widespread prevalence of NoV infections, the need for specific prevention strategies is becoming
apparent.
The literature search was limited to English language publication since 2006. Lack of high quality
comparative studies on the effectiveness of infection control strategies led to the inclusion of lower
level evidence from observational studies therefore findings should be generalised to the clinical
setting with caution. High quality comparative studies are needed to evaluate the effectiveness of
infection control strategies in order to make meaningful recommendations for clinical practice.

P a g e | 31
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Page |1

In healthcare settings, what is the current

Division of Health Sciences

University of South Australia 2017

University of South Australia 2017

In healthcare settings, what is the current epidemiology and latest evidence on

Norovirus is the most frequently occurring cause of community-acquired acute gastroenteritis in

University of South Australia 2017

Specifically, the three review questions of this literature review were:

Please refer the Technical Report for detailed review process.

University of South Australia 2017

Review Condition Context Population Outcomes Study Designs

University of South Australia 2017

PRISMA Flow Diagram

Records identified through Additional records identified

Records screened Records excluded

Full-text articles assessed Full-text articles excluded,

Studies included in the

Figure 1. The study selection process

University of South Australia 2017

Characteristics of included studies

Table 1 Included studies and the methodological quality

Reference Study design Level of Evidence1 Methodological

University of South Australia 2017

Table 2. Details of healthcare settings, participants and study duration

Reference Healthcare setting Participants Study duration

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USA older adults

Q 1: Epidemiology for Norovirus Gastroenteritis in healthcare

University of South Australia 2017

Reference Norovirus Outbreaks/NoV detection/ Screening methods

University of South Australia 2017

1 (1%) and dermatology 1 (1%)].

University of South Australia 2017

Prevalence of Norovirus Geno-groups

Table 4. Details of Norovirus Genogroups prevalence in healthcare settings

Reference Healthcare Outbreaks/NoV Norovirus genogroups

University of South Australia 2017

University of South Australia 2017

Hospitalised Adults and patients with recognized

Clinical features of norovirus gastroenteritis in outbreaks

Table 5. Details of clinical features, symptom duration and populations

Reference Clinical features Duration Population

University of South Australia 2017

Vomiting (57%) and

Reference Clinical features Duration Population

Q 2: Transmission pathways for Norovirus Gastroenteritis in

University of South Australia 2017

Table 6. Details of NoV major transmission pathways

Reference Transmission pathways Transmission Norovirus genogroups

University of South Australia 2017

Table 7. Summary of viral transmission via aerosols

Reference /Healthcare setting Summary of possible aerosol transmission

NoV Shedding in healthcare settings

University of South Australia 2017

Reference Population Virus shedding Norovirus genogroups/

Virus shedding may be detected after

Virus shedding may be detected

(Simon et al. 2006) Stool and vomitus Follow-up investigation No details