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Surveillance for Norovirus Outbreaks

Noroviruses spread when people have contact with infected people often spread through food preparation activities such as the ones shown in this photograph.Noroviruses spread when people have contact with infected people, consume contaminated food or water, or touch contaminated objects. Outbreaks occur often and can happen to people of all ages in a variety of settings.

Noroviruses are the leading cause of reported outbreaks of gastroenteritis (vomiting, diarrhea, and stomach cramping caused by inflammation of the stomach and intestines). While the vast majority of norovirus illnesses are not part of a recognized cluster, outbreaks provide important information on how the virus spreads and, therefore, how best to prevent infection.

Norovirus outbreaks occur throughout the year. But, over 80% of the outbreaks occur from November to April. Also, when there are new strains of norovirus, the number of outbreaks can sometimes increase. This occurred in the winter of 2006 to 2007 with the Minerva strain. However, a new strains that appeared in 2009 (New Orleans) and 2012 (Sydney) did not lead to more outbreaks in the United States. However, the Sydney strain is currently the leading cause of norovirus outbreaks in the United States.

Most outbreaks are caused when norovirus is spread from infected people to others. But, the virus can also spread by consuming contaminated food or water and touching things that have the virus on them. People can get norovirus illness many times during their lifetime. Outbreaks can affect people of all ages and in a variety of settings.

Norovirus in Long-Term Care and Other Healthcare Facilities

Healthcare facilities, including nursing homes and hospitals, are the most commonly reported settings for norovirus outbreaks in the United States and other industrialized countries (see Norovirus in Healthcare Settings). Over half of all norovirus outbreaks reported in the United States occur in long-term care facilities.

The virus can be introduced into healthcare facilities by infected patients—who may or may not be showing symptoms—or by staff, visitors, or contaminated foods. Outbreaks in these settings can be quite long, sometimes lasting months. Illness can be more severe, occasionally even fatal, in hospitalized or nursing home patients compared with otherwise healthy people.

Norovirus in Restaurants and Catered Events

Norovirus is the leading cause of foodborne-disease outbreaks in the United States. About half of all foodborne-disease outbreaks due to a known cause that were reported to CDC from 2006 to 2010 were attributed to norovirus.

Food can get contaminated with norovirus at any point when it is being grown, shipped, handled, or prepared. A variety of foods have caused outbreaks. But, foods that are eaten raw, such as leafy vegetables, fruit, and shellfish, are most commonly involved in norovirus outbreaks.

Most norovirus outbreaks from contaminated food occur in the food service settings like restaurants. Infected food workers are frequently the source of these outbreaks, often by touching ready-to-eat foods, such as raw fruits and vegetables, with their bare hands before serving them. (See For Food Workers: Norovirus and Working with Food.)

Norovirus outbreaks can also occur from fecal (stool) contamination of certain foods at their source. For example, oysters harvested from contaminated water and raspberries irrigated with contaminated water have caused norovirus outbreaks.

For more information, see Foodborne Disease Outbreak Surveillance.

Norovirus on Cruise Ships

Over 90% of diarrheal disease outbreaks on cruise ships are caused by norovirus (see Facts about Noroviruses on Cruise Ships). Norovirus can be especially challenging to control on cruises ships because of the close living quarters, shared dining areas, and rapid turnover of passengers. When the ship docks, norovirus can be brought on board in contaminated food or water or by passengers who were infected while ashore. Repeated outbreaks on consecutive cruises may also result from infected crew or environmental contamination. This is because norovirus can persist on surfaces and is resistant to many common disinfectants.

Norovirus in Schools and Other Institutional Settings

Norovirus outbreaks occur in a range of other institutional settings, for example, schools, child care centers, colleges, prisons, and military encampments. Norovirus outbreaks on university campuses have led to campus closures. Norovirus was the most common cause of gastroenteritis in U.S. Marines during Operation Iraqi Freedom and a common cause of outbreaks among British troops deployed to Iraq during 2002 to 2007.

CDC's Role in Norovirus Outbreaks

While most norovirus outbreaks are investigated by state and local public health authorities, CDC coordinates outbreaks that involve multiple states. Such outbreaks may result from contaminated food that is widely distributed to various states or from an event that involves participants from multiple states.

When requested, CDC also provides technical consultation and assistance to state and local public health agencies during norovirus outbreaks. CDC is also working to improve state and local laboratory capacity and can provide diagnostic support, if requested, to help confirm and report norovirus outbreaks.

National surveillance systems for norovirus outbreaks coordinated by CDC include:

  • Logo: NORS; National Outbreak Reporting SystemNORS
    CDC launched the National Outbreak Reporting System (NORS) launched by CDC in 2009 to collect information on outbreaks of foodborne, waterborne, and enteric disease that spread from person-to-person, animals, environmental surfaces, and other or unknown ways. Public health agencies can report all outbreaks of gastroenteritis, including norovirus illness, through this web-based system.
  • CaliciNet
    CaliciNet is a national norovirus outbreak surveillance network of federal, state, and local public health laboratories in the United States. CDC launched CaliciNet in 2009 to collect information on norovirus strains associated with gastroenteritis outbreaks in the United States.
  • NoroSTAT
    CDC established the Norovirus Sentinel Testing and Tracking (NoroSTAT) network in August 2012. NoroSTAT is a collaborative network of five state health departments and CDC working together to establish and maintain standard practices for norovirus outbreak reporting to CDC surveillance systems.

Data Sources