1. New Norovirus Surveillance Test Kit LT Michael Kramer Environmental Health Officer Navy Environmental and Preventive Medicine Unit TWO

2. 1 Navy Environmental and Preventive Medicine Unit TWO  Disclaimer: The views expressed in this presentation are those of the author and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, nor the U. S. Government. NAVY ENVIRONMENTAL AND PREVENTIVE MEDICINE UNIT TWO

3. 2 Navy Environmental and Preventive Medicine Unit TWO  Provides public health services to Fleet and Shore units within the Navy and Marine Corps.  Composed of 5 main Departments: o Admin o Fleet o Threat o Deployable Platform Department (DPD) o Lab  Active Duty/Civilian personnel consisting of Audiologists, Biochemists, Entomologists, Environmental Health, Health Promotions, Industrial Hygiene, Microbiologists, Occupational and Prev Med Doctors and Preventive Medicine Technicians. NAVY ENVIRONMENTAL AND PREVENTIVE MEDICINE UNIT TWO

4. 3 Microbiology Lab  Provides support and assistance for the Navy and Marine Corps in areas of: o Outbreak or contact investigations o Diagnostic testing and research o Detection of bioterrorism agents o Training and consultative services  COLA accredited NAVY ENVIRONMENTAL AND PREVENTIVE MEDICINE UNIT TWO

5. 4 Norovirus Overview  A group of non-enveloped single-stranded RNA viruses that causes acute gastroenteritis (AGI).  Belong to the family of Caliciviridae  Currently 6 recognized Norovirus genogroups o Three of which cause acute gastroenteritis o GI, GII and GIV NAVY ENVIRONMENTAL AND PREVENTIVE MEDICINE UNIT TWO

6. 5 Foodborne Illness Overview  Norovirus is the leading cause of acute gastroenteritis in the U.S.  Directly attributed to: o 19 – 21 million illnesses o 56,000 – 71,000 hospitalizations o 570 – 800 deaths  Account more than 50% of AGI Outbreaks NAVY ENVIRONMENTAL AND PREVENTIVE MEDICINE UNIT TWO

7. 6 Impact  Global impact  ~ 21 million annually in U.S.  Most common cause of non- bacterial gastroenteritis  50% GI outbreaks NAVY ENVIRONMENTAL AND PREVENTIVE MEDICINE UNIT TWO

8. 7 State of Reporting in the Fleet  Norovirus is hard o Most individuals don’t get tested o Testing is not commonly available at most military treatment facilities (MTF’s)  January 1 2012 – December 31 2014 o 31 Outbreak reports o 18 of these or 58% are either confirmed or suspected norovirus o Vast majority of remaining 13 appear norovirus given symptomology and duration NAVY ENVIRONMENTAL AND PREVENTIVE MEDICINE UNIT TWO

9. 8 Highly Virulent  Low infectious dose = 10 particles  Pre-symptomatic viral shedding  Peaks 2-5 days post-onset  Peak viral load ~100 billion virus particles per gram of feces  1 patient can infect 50% or more of the people around them  Large populations in enclosed environments are most vulnerable NAVY ENVIRONMENTAL AND PREVENTIVE MEDICINE UNIT TWO

10. 9 Symptoms  Watery non-bloody diarrhea  Abdominal cramps  Nausea  Acute-onset explosive (projectile) vomiting  Occasional low grade fever  Incubation Period: o 24-48 Hours  Self Limiting: o Usually 24-72 hours NAVY ENVIRONMENTAL AND PREVENTIVE MEDICINE UNIT TWO

11. 10 Transmission  Person to person o Fecal – oral o Airborne inhalation of droplets o Environmental contamination  Foodborne o Infected food handlers o Food distribution  Waterborne o Large community outbreaks (recreational and drinking water as vehicle) NAVY ENVIRONMENTAL AND PREVENTIVE MEDICINE UNIT TWO

12. 11 Prevention NAVY ENVIRONMENTAL AND PREVENTIVE MEDICINE UNIT TWO

13. 12 State of Outbreak Reporting  Known outbreaks are not often reported and burden of disease uncertain  USS Abraham Lincoln : 21 May – 3 June 2012 o Total case documented in CVN 72 Medical = 214 o Total lost work days = 90 o Conservatively 250+ khaki personnel did not report to Medical o No mission degradation NAVY ENVIRONMENTAL AND PREVENTIVE MEDICINE UNIT TWO

14. 13 Recent Outbreak Data USS LINCOLN (CVN-72) NAVY ENVIRONMENTAL AND PREVENTIVE MEDICINE UNIT TWO Number of Patients33201224267292325187134 Lost Work Days00658904161178 5

15. 14 How Big is the Problem? NAVY ENVIRONMENTAL AND PREVENTIVE MEDICINE UNIT TWO

16. 15 Burden of Norovirus in the United States. NAVY ENVIRONMENTAL AND PREVENTIVE MEDICINE UNIT TWO

17. 16 State of Reporting Aboard U.S. Navy Ships NAVY ENVIRONMENTAL AND PREVENTIVE MEDICINE UNIT TWO

18. 17 Total Outbreaks of AGI in U.S. Navy Ships NAVY ENVIRONMENTAL AND PREVENTIVE MEDICINE UNIT TWO

19. 18 Outbreaks of AGI in the Fleet by Ship Class NAVY ENVIRONMENTAL AND PREVENTIVE MEDICINE UNIT TWO

20. 19 Outbreak?  Persons cleaning areas heavily contaminated with vomitus or feces should wear N95 mask.  Surgical mask provides no protection vs Norovirus  Use chlorine bleach or EPA approved disinfectants  Place patients in private rooms or cohort such patients  Simple routine daily cleaning of ship’s heads, targeting frequently touched areas o Ongoing intrusive leadership to ensure rigorous attention to hygiene and sanitation countermeasures o Closed self-service food line NAVY ENVIRONMENTAL AND PREVENTIVE MEDICINE UNIT TWO

21. 20 Eureka Moment  Developed a fast, economical way to test the burden of norovirus in the Fleet  Takes out the guess work in norovirus surveillance  Help with more accurate reporting and risk assessment  Takes up fewer resources  No cost to ship. NAVY ENVIRONMENTAL AND PREVENTIVE MEDICINE UNIT TWO

22. 21 Test Kit NAVY ENVIRONMENTAL AND PREVENTIVE MEDICINE UNIT TWO

23. 22 Test Kit NAVY ENVIRONMENTAL AND PREVENTIVE MEDICINE UNIT TWO

24. 23 Specimen Collection Procedural Guidelines NAVY ENVIRONMENTAL AND PREVENTIVE MEDICINE UNIT TWO

25. 24 Procedure NAVY ENVIRONMENTAL AND PREVENTIVE MEDICINE UNIT TWO Filter Card Fecal Collection Procedural Guidelines

26. 25NAVY ENVIRONMENTAL AND PREVENTIVE MEDICINE UNIT TWO Summary of Presentation Old MethodNew Method Large footprintTakes up very little space Requires freezingRoom temperature storage Needs dry ice for shippingShipped at room temperature Collected by health care providerCollected by patient Expensive extraction kitVery inexpensive extraction Difficult to use as screening toolEasy to screen many samples

27. 26 Questions? Contact NEPMU-2 Microbiology Laboratory NEPMU2Norfolk-MicroBiology@med.navy.mil NAVY ENVIRONMENTAL & PREVENTIVE MEDICINE UNIT TWO NORFOLK, VA 757-953-6600 NAVY ENVIRONMENTAL AND PREVENTIVE MEDICINE UNIT TWO