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Norovirus and Norovirus-Like Illness (NLI) in Michigan
Jennifer C. Beggs, MPHMichigan Department of Health and Human Services
Communicable Disease Division
Norovirus
Incubation: 12–48 hours (median 33–36 hours) Duration: 12–60 hours Symptoms: diarrhea, vomiting, nausea,
abdominal cramping, low grade fever Survival on surfaces: 40°F, >60 days 68°F (room temp), 21-28 days 98.6°F, less than 1 day
Norovirus
Viral shedding: up to 2–3 weeks (peaks at 4 days)
1010 viral particles per gram of feces Infectious dose: 18–1,000 virus particles
Less than 20 virons (virus particles) can be infectious
Virons can stick together like Velcro and form a clump (usually containing 20–30 virons)
Short-term immunity:
Disease Burden Estimates per Year, United States
21 million cases 1.7 million outpatient visits 414,000 ED visits 71,000 hospitalizations 800 deaths
Required Outbreak Reporting: Public Health
R 325.173 Details the reporting requirements for health care providers, health care facilities, and clinical laboratories
R 325.174 Gives local and state public health officials the authority to investigate possible cases of illness
www.michigan.gov/orr
Disease Reporting “…report any unusual
occurrence, outbreak, or epidemic of any disease or condition including healthcare-associated infections.”
Report within 24 hours of outbreak detection
Report to LHD or MDCH Any information pertinent to
the outbreak should be reported E.g., Number ill, onset,
incubation, duration, organism, control measures
Disinfection Virus is viable up to 7 days on inanimate
objects Must remove visible contaminants of
vomitus and diarrhea prior to disinfection Use dilute bleach (inexpensive and effective) Alternatives:
EPA-registered disinfectants Accelerated Hydrogen Peroxide Glutaraldehyde (0.5%) Iodine (0.8%) Lysol® or Pinesol® (2–4x manufacturer's
recommended concentration)
Disinfection Concentrations
Stainless steel, food/mouth items, toys 200ppm 1 tablespoon of bleach to 1 gallon of water
Non-porous surfaces, tile floors, counter-tops, sinks, toilets 1000ppm 1/3 cup bleach to 1 gallon of water
Porous surfaces, wooden floors 5000ppm 1 and 1/2 cup bleach to 1 gallon water
Norovirus-Like Illness (NLI) Outbreak Definition
Gastrointestinal illness (GI) clusters are defined as NLI outbreaks when:
Cases present with signs and symptoms consistent with norovirus infection
Are not laboratory confirmed as norovirus For facilities (e.g., hospitals, schools,
daycares, prisons), GI activity is above normal baseline
NLI Outbreaks per Year, Michigan 2004–2019*
4834
147120
138 128141
157
198
165
129
163180
145 154
73
0
50
100
150
200
250
Year * As of April 9, 2019
Num
ber o
f Out
brea
ks
NLI Outbreaks and Case Counts1, Michigan 2014–2019*
1 Case counts based on initial report
YearTotal
Outbreaks Cases2014 129 3,2922015 163 3,8202016 180 3,9242017 145 4,5432018 154 2,5132019* 73 1,128
* As of April 9, 2019
2005
Norovirus Outbreaks 2005
RegionCountyType# illWhenConfirmed?Multi-jurisdictional?Multi-State?
1LenaweeHealthcare-related13Apr-05No
1ShiawasseeOther29Jun-05Yes
3GeneseeRestaurant - related8Jan-05Yes
3GeneseeSchool related25Oct-05No
3MidlandHealthcare-related40Feb-05Yes
3SaginawHealthcare-related35Jan-05Yes
5BarrySchool-related/other50Apr-05No
5BerrienRestaurant - related9Apr-05No
5BerrienRestaurant - related5Apr-05No
5BerrienHealthcare-related16Dec-05Yes
5KalamazooSchool-related160Nov-05Yes
5St. JosephOther8Feb-05Yes
5Van-BurenOther100Mar-05Yes
6IoniaSchool-related/other150Oct-05Yes
6KentHealthcare-related14Feb-05Yes
6KentHealthcare-related104Feb-05Yes
6KentRestaurant - related86May-05Yes
6KentSchool-related100Nov-05No
6MecostaOther55May-05Yes
7Grand TraverseOther30May-05Yes
8DickinsonSchool-related/other25Jun-05Yes
8MackinacHealthcare-related14Jan-05Yes
8Western UPRestaurant - related9Jun-05Yes
2NMacombRestaurant - related5Mar-05Yes
2NOaklandRestaurant - related5Jan-05No
2NOaklandOther40Aug-05Yes
2NOaklandSchool-related100Dec-05Yes
2NOaklandSchool-related105Dec-05Yes
2NOaklandSchool-related50Dec-05Yes
2SCity of DetroitHealthcare-related7Jan-05Yes
2SWashtenawSchool-related43Jan-05No
2SWayneRestaurant - related13Apr-05No
OHIOWoodOther16Mar-05YesYes
2006
Norovirus Outbreaks 2006
RegionCountyType# illWhenConfirmed?Multi-jurisdictional?Multi-State?
1ClintonHealthcare facility related229/6/06negative
1EatonRestaurant related4951/28/06YesYes
1EatonRestaurant related1424/27/06YesYes
1EatonRestaurant related21511/29/06YesYes
1EatonHealthcare facility related5512/19/06not tested
1EatonHealthcare facility related1412/26/06not tested
1GratiotHealthcare facility related3212/26/06
1InghamRestaurant related2885/4/06YesYes
1InghamHealthcare facility related225/22/06Yes
1InghamHealthcare facility related116/21/06Yes
1InghamHealthcare facility related4312/19/06yes
1InghamHealthcare facility related1712/24/06not tested
1InghamHealthcare facility related1212/27/06not tested
1JacksonHealthcare facility related302/10/06Yes
1JacksonRestaurant related804/7/06YesYes
1JacksonHealthcare facility related4311/20/06Yes
1Jacksonother - prison20012/20/06yes
1JacksonHealthcare facility related3112/27/06yes
1JacksonRestaurant related1412/27/06yes
1LenaweeRestaurant related188/17/06Yes
1LivingstonHealthcare facility related422/22/06Yes
1LivingstonRestaurant related136/9/06No
1ShiawasseeHealthcare facility related2012/1/06yes
1ShiawasseeHealthcare facility related512/11/06yes
1ShiawasseeHealthcare facility related2812/28/06not tested
3ArenacHealthcare facility related11/28/06Yes
3ArenacHealthcare facility related12/18/06yes
3BayHealthcare facility related5812/27/06yes
3GeneseeHealthcare facility related503/31/06No
3Geneseeother305/23/06Yes
3Geneseeother126/26/06No
3GeneseeHealthcare facility related377/21/06Yes
3GeneseeHealthcare facility related1711/14/06Yes
3GeneseeHealthcare facility related4311/29/06not tested
3GladwinHealthcare facility related4811/16/06Yes
3GladwinHealthcare facility related2911/20/06Yes
3HuronHealthcare facility related6812/27/06yes
3Indiana wedding - Tuscola Co residentsother610/28/06YesYesYes
3SaginawHealthcare facility related325/23/06Yes
3SaginawHealthcare facility related306/22/06Yes
3Saginawother239/20/06Yes
3Saginawother239/23/06Yes
3SaginawRestaurant related911/29/06yes
3Sanilacother - potluck612/7/06yesyesyes
3TuscolaHealthcare facility related55/23/06No
3TuscolaRestaurant related105/30/06Yes
5Alleganother158/15/06Yes
5AlleganHealthcare facility related4311/6/06Yes
5AlleganHealthcare facility related4312/27/06not tested
5BerrienSchool/Camp/Daycare related402/1/06negative
5BerrienHealthcare facility related373/7/06Yes
5Berrienother4011/3/06not tested
5KalamazooRestaurant related212/24/06Yes
5KalamazooRestaurant related73/14/06negative
5KalamazooSchool/Camp/Daycare related53/16/06No
5Kalamazooother65/6/06No
5KalamazooHealthcare facility related256/14/06Yes
5KalamazooSchool/Camp/Daycare related209/20/06not tested
5KalamazooSchool/Camp/Daycare related209/20/06not tested
5KalamazooHealthcare facility related1510/25/06Yes
5KalamazooHealthcare facility related1112/12/06not tested
5KalamazooHealthcare facility related3712/12/06yes
5KalamazooHealthcare facility related3412/24/06nt
5KalamazooHealthcare facility related1512/26/06not tested
5St. Josephother305/5/06YesYesYes
5St. JosephHealthcare facility related2512/31/06nt
6ClareRestaurant related2812/12/06yes
6ClareRestaurant related6512/12/06yes
6IoniaHealthcare facility related305/30/06No
6IsabellaHealthcare facility related235/1/06Yes
6IsabellaHealthcare facility related4211/28/06yes
6IsabellaSchool/Camp/Daycare related412/5/06not tested
6KentHealthcare facility related491/26/06No
6KentHealthcare facility related802/14/06Yes
6KentRestaurant related264/25/06Yes
6KentHealthcare facility related205/18/06Yes
6KentHealthcare facility related205/30/06Yes
6KentHealthcare facility related206/2/06Yes
6KentHealthcare facility related226/4/06Yes
6KentHealthcare facility related236/21/06Yes
6Kentother407/31/06YesYes
6KentHealthcare facility related10011/6/06Yes
6KentHealthcare facility related1411/22/06Yes
6KentHealthcare facility related2112/4/06yes
6KentHealthcare facility related12/5/06yes
6MasonSchool/Camp/Daycare related201/25/06No
6MuskegonSchool/Camp/Daycare related502/6/06YesYes
6MuskegonRestaurant related208/15/06Yes
6Oceanaother655/24/06YesYesYes
6OceanaSchool/Camp/Daycare related176/15/06Yes
6OttawaHealthcare facility related285/5/06Yes
6Ottawaother155/15/06YesYesYes
6OttawaHealthcare facility related135/16/06Yes
6OttawaHealthcare facility related216/4/06Yes
6OttawaSchool/Camp/Daycare related406/9/06YesYes
7CharlevoixHealthcare facility related804/14/06Yes
7Charlevoixother506/15/06NoYes
7CharlevoixHealthcare facility related327/25/06Yes
7CheyboyganHealthcare facility related?6/26/06No
7CrawfordSchool/Camp/Daycare related365/18/06Yes
7EmmetHealthcare facility related5012/5/06not tested
7ManisteeHealthcare facility related308/3/06Yes
7OsceolaHealthcare facility related407/28/06Yes
7OscodaHealthcare facility related3012/27/06not tested
7Presque IsleRestaurant related186/26/06YesYes
7RoscommonRestaurant related1711/30/06yesYes
8BaragaSchool/Camp/Daycare related655/9/06Yes
8ChippewaHealthcare facility related1312/12/06yes
8ChippewaHealthcare facility related1412/15/06yes
8ChippewaHealthcare facility related2812/29/06not tested
8DickinsonHealthcare facility related1510/30/06Yes
8Marquetteother103/30/06No
2NMacombRestaurant related156/5/06No
2NMacombother1110/26/06Not tested
2NMacombHealthcare facility related2311/2/06Yes
2NMacombHealthcare facility related512/7/06not tested
2NOaklandHealthcare facility related183/9/06Yes
2NOaklandRestaurant related44/5/06No
2NOaklandRestaurant related295/3/06Yes
2NOaklandHealthcare facility related115/10/06No
2NOaklandHealthcare facility related1712/4/06yes
2NOaklandRestaurant related1012/6/06yesyes
2NOaklandRestaurant related612/12/06not tested
2NOaklandRestaurant related1212/12/06not tested
2NOaklandHealthcare facility related1012/20/06Yes
2NOaklandHealthcare facility related1012/26/06not tested
2NOaklandHealthcare facility related1812/26/06not tested
2NOaklandHealthcare facility related4012/26/06not tested
2NOaklandHealthcare facility related5812/26/06not tested
2NOaklandHealthcare facility related12/27/06not tested
2NSt ClairHealthcare facility related2011/6/06Yes
2NSt. ClairHealthcare facility related811/20/06yes
2NSt. ClairHealthcare facility related6311/28/06yes - epilink
2SCity of DetroitRestaurant related11/1/06not testedYes
2SCity of DetroitRestaurant related411/27/06not tested
2SDetroit CityHealthcare facility related52/17/06No
2SDetroit Cityother207/28/06NoYes
2SWashtenawRestaurant related452/3/06No
2SWashtenawHealthcare facility related1004/13/06negative
2SWashtenawother1807/25/06YesYes
2SWashtenawRestaurant related5012/5/06yes
2SWashtenawHealthcare facility related912/13/06not tested
2SWashtenawHealthcare facility related1812/13/06not tested
2SWashtenawHealthcare facility related2212/13/06not tested
2SWayneRestaurant related501/21/06No
2SWayneother3510/25/06YesYesYes
2SWayneother - Crystal Gardens1011/22/06negative
2007
Norovirus Outbreaks 2007
RegionCountyType# illWhenConfirmed?Multi-jurisdictional?Multi-State?
1ClintonHCF2512/21/07nt
1EatonHCF269/18/07negative
1EatonSchool23010/27/07Yes
1GratiotHCF63/23/07Yes
1HillsdaleOther/school123/20/07nt
1InghamHCF1/22/07nt
1InghamHCF161/22/07nt
1InghamRestaurant145/4/07nt
1Inghamother65/9/07nt
1Jacksonother372/27/07Yes
1JacksonHCF124/20/07nt
1JacksonHCF244/25/07nt
1JacksonHCF285/9/07nt
1JacksonHCF126/18/07nt
1JacksonHCF1911/5/07negative
1JacksonSchool7012/10/07nt
1JacksonHCF1112/13/07Yes
1LenaweeHCF131/5/07nt
1LenaweeHCF234/19/07nt
1LivingstonOther304/19/07YesYes
3BayHCF1271/11/07nt
3BayHCF351/26/07nt
3GeneseeSchool20012/21/07
3HuronHCF273/27/07nt
3MidlandHCF373/7/07nt
3SaginawHCF371/23/07nt
3SaginawRestaurant47/2/07nt
3SanilacOther1510/23/07nt
3SanilacOther5011/28/07negative
3TuscolaHCF221/11/07nt
3TuscolaHCF131/27/07nt
3TuscolaHCF192/23/07nt
5BerrienRestaurant-related1911/13/07Yes
5BerrienHealthcare facility related4612/28/07nt
5BranchRestaurant105/17/07nt
5CalhounHCF472/16/07nt
5CalhounHCF4312/3/07Yes
5CalhounRestaurant-related1812/18/07Yes
5CassOther125/18/07nt
5KalamazooHCF481/2/07nt
5KalamazooHCF151/10/07nt
5KalamazooHCF252/2/07nt
5KalamazooSchool82/6/07nt
5KalamazooSchool173/29/07nt
5KalamazooSchool194/26/07nt
5KalamazooSchool255/1/07nt
5KalamazooOther116/21/07nt
5KalamazooHCF99/19/07nt
5KalamazooRestaurant-related510/5/07nt
5KalamazooSchool912/20/07Yes
5KalamazooHealthcare facility related4212/23/2007 (reported in 1/18)nt
5St. JosephOther407/10/07Yes
5St. JosephOther307/25/07Yes
5Van BurenHCF72/5/07nt
5Van BurenSchool309/14/07nt
6ClareHCF121/2/07nt
6Ioniaother3001/10/07Yes
6IsabellaOther1212/17/07negative
6IsabellaOther812/21/07
6KentHCF301/5/07nt
6KentHCF231/8/07nt
6KentHCF1231/15/07Yes
6KentRestaurant72/14/07nt
6Kentother202/16/07nt
6KentSchool805/9/07YesYes
6MontcalmHCF811/2/07Yes
6MontcalmHCF81/4/07nt
6MuskegonOther103/29/07nt
6MuskegonRestaurant55/22/07negative
6NewaygoHCF312/8/07Yes
6OttawaHCF371/23/07Yes
6OttawaHCF92/6/07nt
6OttawaHCF362/6/07nt
6OttawaHCF92/13/07nt
6OttawaHCF132/14/07nt
6OttawaHCF184/13/07nt
6OttawaOther107/2/07nt
7AlpenaHCF401/29/07nt
7CheyboygenOther538/24/07Yes
7CrawfordHCF201/11/07Yes
7CrawfordOther136/29/07nt
7Grand TraverseOther307/23/07nt
7ManisteeHCF61/24/07nt
7MissawkeeHCF51/11/07nt
7RoscommonHCF411/2/07Yes
8DickinsonHCF1/10/07nt
8LuceHCF291/22/07nt
8MackinacHCF264/19/07Yes
8MarquetteHCF703/15/07nt
8MarquetteHCF53/19/07nt
8MarquetteHCF243/19/07nt
8SchoolcraftOther/resturant253/26/07nt
2NMacombRestaurant-related118/11/07Yes
2NOaklandHCF241/8/07Yes
2NOaklandHCF145/2/07nt
2NOaklandother1005/4/07nt
2NOaklandSchool225/17/07nt
2NOaklandOther126/11/07nt
2NOaklandOther167/11/07nt
2NOaklandHCF10/19/07negative
2NOaklandHCF410/30/07nt
2NOaklandRestaurant-related1312/21/07nt
2NSt. Clairother/rest121/25/07nt
2NSt. ClairHCF112/5/07nt
2NSt. ClairHCF3/26/07nt
2NSt. ClairHCF911/21/07nt
2SMonroeSchool11012/21/07nt
2SWashtenawSchool202/1/07nt
2SWashtenawHCF103/5/07nt
2SWashtenawHCF93/9/07nt
2SWashtenawSchool406/18/07nt
2SWashtenawOther118/15/07nt
2SWashtenawOther118/15/07ntfamily reunion in TN
2SWashtenawHCF5011/27/07nt
2SWayneHCF171/24/07nt
2SWayneRestaurant123/15/07nt
2SWayneOther223/21/07Yes
2SWayneSchool4/3/07nt
2SWayneOther165/18/07Yes
2SWayneOther506/22/07Yes
2SWayneOther2010/30/07nt
2008
Norovirus Outbreaks January 2008-present
RegionCountyType# ill (est.)WhenConfirmed?Multi-jurisdictional?Multi-State?
5KalamazooH131/1/08ntnono
5KalamazooH261/4/08ntnono
2NOaklandH101/7/08ntnono
1ShiawasseeH81/10/08ntnono
6KentR111/11/08Yes
1BEDHDR41/4/08nt
2NOaklandH51/22/08ntnono
2NOaklandR81/19/08nt
5CalhounH471/30/08ntnono
5KalamazooH72/1/08ntnono
2SWayneH212/12/08ntnono
1ShiawasseeH82/11/08ntnono
2NMacombH2/15/08ntnono
2NMacombH152/15/08ntnono
3GeneseeS202/15/08
6MasonH682/19/08
271
Sheet1
YearTotal OutbreaksCases
20141293,292
20151633,820
20161803,924
20171454,543
20181542,513
2019*731,128
0
10
20
30
40
50
6015
-Jan Mar
May Ju
lSe
ptN
ov16
-Jan Mar
May Ju
lSe
ptN
ov17
-Jan Mar
May Ju
lSe
ptN
ov18
-Jan Mar
May Ju
lSe
ptN
ov19
-Jan Mar
NLI Outbreaks by Onset Date per Month, Michigan Jan 2015–April 2019*
Year and Month
Num
ber o
f Out
brea
ks
* As of April 9, 2019
43
30
16
7 8
13 3
5 4 6
22
39
31
20 21
4
13
1 1 1
5
2728
20
25
0
05
10152025303540455017
-Jan Fe
bM
arA
prM
ayJu
ne Jul
Aug
Sept
Oct
Nov Dec
18-J
an Feb
Mar
Apr
May
June Ju
lA
ugSe
ptO
ctN
ov Dec
19-J
an Feb
Mar
Apr
*
NLI Outbreaks by Onset Date per Month, Michigan Jan 2017–April 2019*
Year and Month
Num
ber o
f Out
brea
ks
* As of April 9, 2019
NLI Outbreaks by Onset Date per Month, Michigan 2015–2019*
Num
ber o
f Out
brea
ks
0
10
20
30
40
50
60
Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec
20152016201720182019*
* As of April 9, 2019
Percentage of NLI Associated Settings, Michigan 2015–2019*
0
10
20
30
40
50
60
70
80
2015 2016 2017 2018 2019*Healthcare School Foodborne OtherP
erce
nt (%
) of N
LI O
utbr
eaks
* As of April 9, 2019
NLI Outbreaks by Region, Michigan 2016–2019*
0
5
10
15
20
25
30
35
40
45
1 2N 2S 3 5 6 7 82016 20172018 2019** As of April 9, 2019
Num
ber o
f NLI
Out
brea
ks
Region
Percentage of PCR Confirmed Norovirus Outbreaks, Michigan 2019*
1%22%
4%3%
70%
Norovirus GI
Norovirus GII
Negative
Sapovirus
Not Tested
N = 73
* As of April 9, 2019
Percentage of PCR Confirmed Norovirus Outbreaks, Michigan 2018
3%
22%
5%1%69%
Norovirus GI
Norovirus GII
Negative
Sapovirus
Not Tested
N = 154
Percentage of PCR Confirmed Norovirus Outbreaks, Michigan 2017
3% 13%
1%
81%
1%1%
Norovirus GINorovirus GIINorovirus GI and GIINot TestedNorovirus NegativeAstrovirus
N = 145
Percentage of PCR Confirmed Norovirus Outbreaks, Michigan 2016
4%
22%
1%
71%
2%
Norovirus GI
Norovirus GII
Norovirus GI and GII
Not Tested
Norovirus Negative
N = 180
Percentage of PCR Confirmed Norovirus Outbreaks, Michigan 2015
2%
30%
60%
8%
Norovirus GI
Norovirus GII
Not Tested
Norovirus Negative
N = 163
NLI Outbreak Laboratory Results, Michigan 2016–2019*
Result: 2016 Count
2017 Count
2018 Count
2019* Count
Norovirus GI and GII 1 1 0 0
Norovirus GI 7 5 4 1
Norovirus GII 41 19 35 16
Sapo/Astro Virus1 0 1 1 2
Noro, Astro, SapovirusNegative
5 2 8 3
Pending 0 0 0 0
Not Tested 126 117 106 51
Total 180 145 154 731Outbreaks that test negative for norovirus are then tested for astrovirus and sapovirus. * As of April 9, 2019
Sequences Identified, Michigan 2016-20182017
GI.3 GI.5 GII.1 GII.2 GII.3 GII.4 New Orleans GII.4 Sydney GII.4 untypeable GII.6 GII.7
2016 GI.3b GI.5 GI.6 GII.3 GII.4 Sydney GII.4 untypeable GII.7
GI.1 GI.6 GI.7 GII.1 GII.2 GII.4 New Orleans GII.4 Sydney GII.4 untypeable
2018
Norovirus Resources
www.michigan.gov/cdinfo
General Norovirus Fact Sheet Guidelines for Environmental Cleaning and
Disinfection of Norovirus Guidelines for the Control of a Suspected or
Confirmed Outbreak of Viral Gastroenteritis in a Nursing Home
Norovirus Investigations in Long Term Care Facilities: Things to Consider
QuestionsJennifer C. Beggs, MPH
Surveillance and Infectious Disease EpidemiologyMichigan Department of Community Health
[email protected](517) 284-4942
www.michigan.gov/cdinfo
Norovirus and Norovirus-Like Illness (NLI) in MichiganNorovirusNorovirusDisease Burden Estimates per Year, United StatesRequired Outbreak Reporting: Public HealthDisease ReportingDisinfectionDisinfection ConcentrationsNorovirus-Like Illness �(NLI) Outbreak DefinitionNLI Outbreaks per Year, �Michigan 2004–2019*NLI Outbreaks and Case Counts1, Michigan 2014–2019* �Slide Number 12NLI Outbreaks by Onset Date per Month, �Michigan Jan 2017–April 2019*NLI Outbreaks by Onset Date per Month, Michigan 2015–2019*Percentage of NLI Associated Settings, Michigan 2015–2019*NLI Outbreaks by Region, Michigan 2016–2019*Percentage of PCR Confirmed Norovirus Outbreaks, Michigan 2019*Percentage of PCR Confirmed Norovirus Outbreaks, Michigan 2018Percentage of PCR Confirmed Norovirus Outbreaks, Michigan 2017Percentage of PCR Confirmed Norovirus Outbreaks, Michigan 2016Percentage of PCR Confirmed Norovirus Outbreaks, Michigan 2015NLI Outbreak Laboratory Results, Michigan 2016–2019*Sequences Identified, Michigan 2016-2018Norovirus ResourcesQuestions