Current Geriatrics Reports

, Volume 6, Issue 1, pp 26–33 | Cite as

Norovirus Disease in Older Adults Living in Long-Term Care Facilities: Strategies for Management

Infectious Diseases in the Elderly (M Schilling, Section Editor)
Part of the following topical collections:
  1. Topical Collection on Infectious Diseases in the Elderly


Purpose of Review

Noroviruses are the most common cause of gastroenteritis outbreaks in long-term care facility (LTCFs). This review summarizes the most up-to-date knowledge on norovirus infection in LTCFs with the aim of identifying potential strategies for management.

Recent Findings

LTCF residents are at greater risk of norovirus infection. Early identification of norovirus infection and prompt initiation of appropriate supportive therapy are required to reduce morbidity and mortality. Measures to prevent outbreaks and reduce the risk of norovirus infection in LTCFs include timely diagnosis and implementation of infection control interventions to limit virus transmission.


Current guidelines for prevention and control are based on generic principles of infection control. Real-time reverse transcription-quantitative polymerase chain reaction assays have been the gold standard for the rapid and sensitive detection of noroviruses. With the recent breakthroughs of human norovirus in vitro culture, doors are now opened to evaluate the efficacy of environmental disinfectants and hand hygiene options. Additionally, development of licensed vaccines against noroviruses may provide another important tool for infection prevention among high-risk individuals.


Norovirus Older adults Long-term care facilities Management 


Compliance with Ethical Standards

Conflict of Interest

Yingxi Chen, Aron Hall and Martyn Kirk declare no conflict of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

Human and Animal Rights

All reported studies/experiments with human or animal subjects performed by the authors have been previously published and complied with all applicable ethical standards (including the Helsinki declaration and its amendments, institutional/national research committee standards, and international/national/institutional guidelines).


The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.


Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    •• Kirk MD, Pires SM, Black RE, Caipo M, Crump JA, Devleesschauwer B, et al. World Health Organization estimates of the global and regional disease burden of 22 foodborne bacterial, protozoal, and viral diseases, 2010: a data synthesis. PLoS Med. 2015;12:e1001921. Most recent estimates of the global burden of 22 foodborne bacterial, protozoal, and viral infections. CrossRefPubMedPubMedCentralGoogle Scholar
  2. 2.
    •• Ahmed SM, Hall AJ, Robinson AE, Verhoef L, Premkumar P, Parashar UD, et al. Global prevalence of norovirus in cases of gastroenteritis: a systematic review and meta-analysis. Lancet Infect Dis. 2014;14:725–30. Reviews the global prevalence of norovirus gastroenteritis. CrossRefPubMedGoogle Scholar
  3. 3.
    Lindsay L, Wolter J, De Coster I, Van Damme P, Verstraeten T. A decade of norovirus disease risk among older adults in upper-middle and high income countries: a systematic review. BMC Infect Dis. 2015;15:425.CrossRefPubMedPubMedCentralGoogle Scholar
  4. 4.
    Kirk MD, Fullerton KE, Hall GV, Gregory J, Stafford R, Veitch MG, et al. Surveillance for outbreaks of gastroenteritis in long-term care facilities, Australia, 2002–2008. Clin Infect Dis. 2010;51:907–14.CrossRefPubMedGoogle Scholar
  5. 5.
    Rosenthal NA, Lee LE, Vermeulen BA, Hedberg K, Keene WE, Widdowson MA, et al. Epidemiological and genetic characteristics of norovirus outbreaks in long-term care facilities, 2003-2006. Epidemiol Infect. 2011;139:286–94.CrossRefPubMedGoogle Scholar
  6. 6.
    • Hall AJ, Wikswo ME, Manikonda K, Roberts VA, Yoder JS, Gould LH. Acute gastroenteritis surveillance through the National Outbreak Reporting System, United States. Emerg Infect Dis. 2013;19:1305–9. Demonstrates a more complete characterization of acute gastroenteritis outbreaks, particularly the relative importance of specific transmission modes and settings for norovirus. CrossRefPubMedPubMedCentralGoogle Scholar
  7. 7.
    Payne R, Forde D, Vedio A, Cope A, Pratt G, Tunbridge A. ‘It’s just a virus’—viral illness in older people: prevention and management. Rev Clin Gerontol. 2013;23:131–41.CrossRefGoogle Scholar
  8. 8.
    Rajagopalan S, Yoshikawa TT. Norovirus infections in long-term care facilities. J Am Geriatr Soc. 2016;64:1097–103.CrossRefPubMedGoogle Scholar
  9. 9.
    Haustein T, Harris JP, Pebody R, Lopman BA. Hospital admissions due to norovirus in adult and elderly patients in England. Clin Infect Dis. 2009;49:1890–2.CrossRefPubMedGoogle Scholar
  10. 10.
    van Asten L, Siebenga J, van den Wijngaard C, Verheij R, van Vliet H, Kretzschmar M, et al. Unspecified gastroenteritis illness and deaths in the elderly associated with norovirus epidemics. Epidemiol. 2011;22:336–43. doi: 10.1097/EDE.0b013e31821179af.CrossRefGoogle Scholar
  11. 11.
    • Gastanaduy PA, Hall AJ, Curns AT, Parashar UD, Lopman BA. Burden of norovirus gastroenteritis in the ambulatory setting--United States, 2001-2009. J Infect Dis. 2013;207:1058–65. Estimates the burden of norovirus gastroenteritis in ambulatory US patients. CrossRefPubMedGoogle Scholar
  12. 12.
    Schmid D, Kuo HW, Simons E, Kanitz EE, Wenisch J, Allerberger F, et al. All-cause mortality in hospitalized patients with infectious diarrhea: Clostridium difficile versus other enteric pathogens in Austria from 2008 to 2010. J Infect Public Health. 2014;7:133–44.CrossRefPubMedGoogle Scholar
  13. 13.
    Hall AJ, Curns AT, McDonald LC, Parashar UD, Lopman BA. The roles of Clostridium Difficile and norovirus among gastroenteritis-associated deaths in the United States, 1999-2007. Clin Infect Dis. 2012;55:216–23.CrossRefPubMedGoogle Scholar
  14. 14.
    Mattner F, Sohr D, Heim A, Gastmeier P, Vennema H, Koopmans M. Risk groups for clinical complications of norovirus infections: an outbreak investigation. Clin Microbiol Infect. 2006;12:69–74.CrossRefPubMedGoogle Scholar
  15. 15.
    Woodward JM, Gkrania-Klotsas E, Cordero-Ng AY, Aravinthan A, Bandoh BN, Liu H, et al. The role of chronic norovirus infection in the enteropathy associated with common variable immunodeficiency. Am J Gastroenterol. 2015;110:320–7.CrossRefPubMedGoogle Scholar
  16. 16.
    Greig JD, Lee MB. Enteric outbreaks in long-term care facilities and recommendations for prevention: a review. Epidemiol Infect. 2009;137:145–55.CrossRefPubMedGoogle Scholar
  17. 17.
    Vega E, Barclay L, Gregoricus N, Shirley SH, Lee D, Vinje J. Genotypic and epidemiologic trends of norovirus outbreaks in the United States, 2009 to 2013. J Clin Microbiol. 2014;52:147–55.CrossRefPubMedPubMedCentralGoogle Scholar
  18. 18.
    • Trivedi TK, Desai R, Hall AJ, Patel M, Parashar UD, Lopman BA. Clinical characteristics of norovirus-associated deaths: a systematic literature review. Am J Infect Control. 2013;41:654–7. Reviews of clinical and epidemiologic characteristics of deaths assocaited with norovirus infection. CrossRefPubMedGoogle Scholar
  19. 19.
    Lopman BA, Reacher MH, Vipond IB, Sarangi J, Brown DW. Clinical manifestation of norovirus gastroenteritis in health care settings. Clin Infect Dis. 2004;39:318–24.CrossRefPubMedGoogle Scholar
  20. 20.
    Kaufman SS, Green KY, Korba BE. Treatment of norovirus infections: moving antivirals from the bench to the bedside. Antivir Res. 2014;105:80–91.CrossRefPubMedPubMedCentralGoogle Scholar
  21. 21.
    Iturriza-Gomara M, Lopman B. Norovirus in healthcare settings. Curr Opin Infect Dis. 2014;27:437–43.CrossRefPubMedPubMedCentralGoogle Scholar
  22. 22.
    Kroneman A, Verhoef L, Harris J, Vennema H, Duizer E, van Duynhoven Y, et al. Analysis of integrated virological and epidemiological reports of norovirus outbreaks collected within the foodborne viruses in Europe network from 1 July 2001 to 30 June 2006. J Clin Microbiol. 2008;46:2959–65.CrossRefPubMedPubMedCentralGoogle Scholar
  23. 23.
    Rodriguez-Lazaro D, Cook N, Ruggeri FM, Sellwood J, Nasser A, Nascimento MS, et al. Virus hazards from food, water and other contaminated environments. FEMS Microbiol Rev. 2012;36:786–814.CrossRefPubMedGoogle Scholar
  24. 24.
    Verhoef L, Hewitt J, Barclay L, Ahmed SM, Lake R, Hall AJ, et al. Norovirus genotype profiles associated with foodborne transmission, 1999-2012. Emerg Infect Dis. 2015;21:592–9.CrossRefPubMedPubMedCentralGoogle Scholar
  25. 25.
    Repp KK, Keene WE. A point-source norovirus outbreak caused by exposure to fomites. J Infect Dis. 2012;205:1639–41.CrossRefPubMedPubMedCentralGoogle Scholar
  26. 26.
    Atmar RL, Opekun AR, Gilger MA, Estes MK, Crawford SE, Neill FH, et al. Norwalk virus shedding after experimental human infection. Emerg Infect Dis. 2008;14:1553–7.CrossRefPubMedPubMedCentralGoogle Scholar
  27. 27.
    Teunis PFM, Moe CL, Liu P, Miller S, Lindesmith L, Baric RS, et al. Norwalk virus: how infectious is it? J Med Virol. 2008;80:1468–76.CrossRefPubMedGoogle Scholar
  28. 28.
    Lopman B, Gastañaduy P, Park GW, Hall AJ, Parashar UD, Vinje J. Environmental transmission of norovirus gastroenteritis. Curr Opin Virol. 2012;2:96–102.CrossRefPubMedGoogle Scholar
  29. 29.
    Ozawa K, Oka T, Takeda N, Hansman GS. Norovirus infections in symptomatic and asymptomatic food handlers in Japan. J Clin Microbiol. 2007;45:3996–4005.CrossRefPubMedPubMedCentralGoogle Scholar
  30. 30.
    Sukhrie FA, Teunis P, Vennema H, Copra C, Thijs Beersma MFC, Bogerman J, et al. Nosocomial transmission of norovirus is mainly caused by symptomatic cases. Clin Infect Dis. 2012;54:931–7.CrossRefPubMedGoogle Scholar
  31. 31.
    •• Costantini VP, Cooper EM, Hardaker HL, Lee LE, Bierhoff M, Biggs C, et al. Epidemiologic, virologic, and host genetic factors of norovirus outbreaks in long-term care facilities. Clin Infect Dis. 2016;62:1–10. Demostrates the epidemiology, virology, and genetic host factors of naturally occurring norovirus outbreaks in LTCF. CrossRefPubMedGoogle Scholar
  32. 32.
    Teunis PF, Sukhrie FH, Vennema H, Bogerman J, Beersma MF, Koopmans MP. Shedding of norovirus in symptomatic and asymptomatic infections. Epidemiol Infect. 2015;143:1710–7.CrossRefPubMedGoogle Scholar
  33. 33.
    Vinje J. Advances in laboratory methods for detection and typing of norovirus. J Clin Microbiol. 2015;53:373–81.CrossRefPubMedPubMedCentralGoogle Scholar
  34. 34.
    Lysen M, Thorhagen M, Brytting M, Hjertqvist M, Andersson Y, Hedlund KO. Genetic diversity among food-borne and waterborne norovirus strains causing outbreaks in Sweden. J Clin Microbiol. 2009;47:2411–8.CrossRefPubMedPubMedCentralGoogle Scholar
  35. 35.
    Hall AJ, Eisenbart VG, Etingue AL, Gould LH, Lopman BA, Parashar UD. Epidemiology of foodborne norovirus outbreaks, United States, 2001-2008. Emerg Infect Dis. 2012;18:1566–73.CrossRefPubMedPubMedCentralGoogle Scholar
  36. 36.
    Bruggink LD, Oluwatoyin O, Sameer R, Witlox KJ, Marshall JA. Molecular and epidemiological features of gastroenteritis outbreaks involving genogroup I norovirus in Victoria, Australia, 2002-2010. J Med Virol. 2012;84:1437–48.CrossRefPubMedGoogle Scholar
  37. 37.
    Desai R, Hembree CD, Handel A, Matthews JE, Dickey BW, McDonald S, et al. Severe outcomes are associated with genogroup 2 genotype 4 norovirus outbreaks: a systematic literature review. Clin Infect Dis. 2012;55:189–93.CrossRefPubMedPubMedCentralGoogle Scholar
  38. 38.
    Ayukekbong JA, Fobisong C, Tah F, Lindh M, Nkuo-Akenji T, Bergstrom T. Pattern of circulation of norovirus GII strains during natural infection. J Clin Microbiol. 2014;52:4253–9.CrossRefPubMedPubMedCentralGoogle Scholar
  39. 39.
    Siebenga JJ, Vennema H, Zheng DP, Vinje J, Lee BE, Pang XL, et al. Norovirus illness is a global problem: emergence and spread of norovirus GII.4 variants, 2001-2007. J Infect Dis. 2009;200:802–12.CrossRefPubMedGoogle Scholar
  40. 40.
    Zheng DP, Widdowson MA, Glass RI, Vinje J. Molecular epidemiology of genogroup II-genotype 4 noroviruses in the United States between 1994 and 2006. J Clin Microbiol. 2010;48:168–77.CrossRefPubMedGoogle Scholar
  41. 41.
    •• de Graaf M, van Beek J, Koopmans MP. Human norovirus transmission and evolution in a changing world. Nat Rev Microbiol. 2016;14:421–33. Most recent review describing the transmission, pathogenesis and evolution of human noroviruses, and considering the ongoing risk of norovirus outbreaks, along with the future prospects for treatment. CrossRefPubMedGoogle Scholar
  42. 42.
    Lindesmith LC, Beltramello M, Donaldson EF, Corti D, Swanstrom J, Debbink K, et al. Immunogenetic mechanisms driving norovirus GII.4 antigenic variation. PLoS Pathog. 2012;8:e1002705.CrossRefPubMedPubMedCentralGoogle Scholar
  43. 43.
    Eden JS, Tanaka MM, Boni MF, Rawlinson WD, White PA. Recombination within the pandemic norovirus GII.4 lineage. J Virol. 2013;87:6270–82.CrossRefPubMedPubMedCentralGoogle Scholar
  44. 44.
    Hasing ME, Lee BE, Preiksaitis JK, Tellier R, Honish L, Senthilselvan A, et al. Emergence of a new norovirus GII.4 variant and changes in the historical biennial pattern of norovirus outbreak activity in Alberta, Canada, from 2008 to 2013. J Clin Microbiol. 2013;51:2204–11.CrossRefPubMedPubMedCentralGoogle Scholar
  45. 45.
    Allen DJ, Adams NL, Aladin F, Harris JP, Brown DW. Emergence of the GII-4 Norovirus Sydney 2012 strain in England, winter 2012-2013. PLoS One. 2014;9:e88978.CrossRefPubMedPubMedCentralGoogle Scholar
  46. 46.
    Lee RM, Lessler J, Lee RA, Rudolph KE, Reich NG, Perl TM, et al. Incubation period of viral gastroenteritis: a systematic review. BMC Infect Dis. 2013;13:446.CrossRefPubMedPubMedCentralGoogle Scholar
  47. 47.
    Tsang OTY, Wong ATY, Chow CB, Yung RWH, Lim WWL, Liu SH. Clinical characteristics of nosocomial norovirus outbreaks in Hong Kong. J Hosp Infect. 2008;69:135–40.CrossRefPubMedGoogle Scholar
  48. 48.
    Stone ND, Ashraf MS, Calder J, Crnich CJ, Crossley K, Drinka PJ, et al. Surveillance definitions of infections in long-term care facilities: revisiting the McGeer criteria. Infect Control Hosp Epidemiol. 2012;33:965–77.CrossRefPubMedPubMedCentralGoogle Scholar
  49. 49.
    •• Jones MK, Grau KR, Costantini V, Kolawole AO, de Graaf M, Freiden P, et al. Human norovirus culture in B cells. Nat Protoc. 2015;10:1939–47. Describes the first cell culture system for a human norovirus. CrossRefPubMedPubMedCentralGoogle Scholar
  50. 50.
    Chan MC, Sung JJ, Lam RK, Chan PK, Lee NL, Lai RW, et al. Fecal viral load and norovirus-associated gastroenteritis. Emerg Infect Dis. 2006;12:1278–80.CrossRefPubMedPubMedCentralGoogle Scholar
  51. 51.
    Wilhelmi de Cal I, Revilla A, del Alamo JM, Roman E, Moreno S, Sanchez-Fauquier A. Evaluation of two commercial enzyme immunoassays for the detection of norovirus in faecal samples from hospitalised children with sporadic acute gastroenteritis. Clin Microbiol Infect. 2007;13:341–3.CrossRefPubMedGoogle Scholar
  52. 52.
    Updated norovirus outbreak management and disease prevention guidelines. MMWR Recomm Rep. 2011;60: 1–18.Google Scholar
  53. 53.
    Kaplan JE, Gary GW, Baron RC, Singh N, Schonberger LB, Feldman R, et al. Epidemiology of Norwalk gastroenteritis and the role of Norwalk virus in outbreaks of acute nonbacterial gastroenteritis. Ann Intern Med. 1982;96:756–61.CrossRefPubMedGoogle Scholar
  54. 54.
    Turcios RM, Widdowson MA, Sulka AC, Mead PS, Glass RI. Reevaluation of epidemiological criteria for identifying outbreaks of acute gastroenteritis due to norovirus: United States, 1998-2000. Clin Infect Dis. 2006;42:964–9.CrossRefPubMedGoogle Scholar
  55. 55.
    Goller JL, Dimitriadis A, Tan A, Kelly H, Marshall JA. Long-term features of norovirus gastroenteritis in the elderly. J Hosp Infect. 2004;58:286–91.CrossRefPubMedGoogle Scholar
  56. 56.
    Lindesmith LC, Ferris MT, Mullan CW, Ferreira J, Debbink K, Swanstrom J, et al. Broad blockade antibody responses in human volunteers after immunization with a multivalent norovirus VLP candidate vaccine: immunological analyses from a phase I clinical trial. PLoS Med. 2015;12:e1001807.CrossRefPubMedPubMedCentralGoogle Scholar
  57. 57.
    Atmar RL, Baehner F, Cramer JP, Song E, Borkowski A, and Mendelman PM. Rapid Responses to Two Virus-Like Particle Norovirus Vaccine Candidate Formulations in Healthy Adults: A Randomized Controlled Trial. J Infect Dis. 2016;In press.Google Scholar
  58. 58.
    •• Lopman BA, Steele D, Kirkwood CD, Parashar UD. The vast and varied global burden of norovirus: prospects for prevention and control. PLoS Med. 2016;13:e1001999. Reviews the evidence for the global burden of norovirus and discusses the prospects for norovirus vaccine development. CrossRefPubMedPubMedCentralGoogle Scholar
  59. 59.
    • Aliabadi N, Lopman BA, Parashar UD, Hall AJ. Progress toward norovirus vaccines: considerations for further development and implementation in potential target populations. Expert Rev Vaccines. 2015;14:1241–53. Discusses recent data on human norovirus vaccine development and potential targets for implementation. PubMedGoogle Scholar
  60. 60.
    MacCannell T, Umscheid CA, Agarwal RK, Lee I, Kuntz G, Stevenson KB. Guideline for the prevention and control of norovirus gastroenteritis outbreaks in healthcare settings. Infect Control Hosp Epidemiol. 2011;32:939–69.CrossRefPubMedGoogle Scholar
  61. 61.
    Hansen S, Stamm-Balderjahn S, Zuschneid I, Behnke M, Ruden H, Vonberg RP, et al. Closure of medical departments during nosocomial outbreaks: data from a systematic analysis of the literature. J Hosp Infect. 2007;65:348–53.CrossRefPubMedGoogle Scholar
  62. 62.
    Communicable Diseases Network Australia, Guidelines for the public health management of gastroenteritis outbreaks due to norovirus or suspected viral agents in Australia. 2010.Google Scholar
  63. 63.
    Party NW. Guidelines for the management of norovirus outbreaks in acute and community health and social care settings. London: Health Protection Agency; 2012.Google Scholar
  64. 64.
    D'Souza DH, Sair A, Williams K, Papafragkou E, Jean J, Moore C, et al. Persistence of caliciviruses on environmental surfaces and their transfer to food. Int J Food Microbiol. 2006;108:84–91.CrossRefPubMedGoogle Scholar
  65. 65.
    Park GW, Sobsey MD. Simultaneous comparison of murine norovirus, feline calicivirus, coliphage MS2, and GII.4 norovirus to evaluate the efficacy of sodium hypochlorite against human norovirus on a fecally soiled stainless steel surface. Foodborne Pathog Dis. 2011;8:1005–10.CrossRefPubMedGoogle Scholar
  66. 66.
    Otter JA, Yezli S, French GL. The role played by contaminated surfaces in the transmission of nosocomial pathogens. Infect Control Hosp Epidemiol. 2011;32:687–99.CrossRefPubMedGoogle Scholar
  67. 67.
    Park GW, Barclay L, Macinga D, Charbonneau D, Pettigrew CA, Vinje J. Comparative efficacy of seven hand sanitizers against murine norovirus, feline calicivirus, and GII.4 norovirus. J Food Prot. 2010;73:2232–8.CrossRefPubMedGoogle Scholar
  68. 68.
    Liu P, Yuen Y, Hsiao HM, Jaykus LA, Moe C. Effectiveness of liquid soap and hand sanitizer against Norwalk virus on contaminated hands. Appl Environ Microbiol. 2010;76:394–9.CrossRefPubMedGoogle Scholar
  69. 69.
    Petrignani M, van Beek J, Borsboom G, Richardus JH, Koopmans M. Norovirus introduction routes into nursing homes and risk factors for spread: a systematic review and meta-analysis of observational studies. J Hosp Infect. 2015;89:163–78.CrossRefPubMedGoogle Scholar
  70. 70.
    Friesema IH, Vennema H, Heijne JC, de Jager CM, Morroy G, van den Kerkhof JH, et al. Norovirus outbreaks in nursing homes: the evaluation of infection control measures. Epidemiol Infect. 2009;137:1722–33.CrossRefPubMedGoogle Scholar
  71. 71.
    • Hall AJ, Wikswo ME, Pringle K, Gould LH, Parashar UD. Vital signs: foodborne norovirus outbreaks - United States, 2009-2012. MMWR Morb Mortal Wkly Rep. 2014;63:491–5. Analysis of surveillance data suggests that food workers were associated with 70% of foodborne norovirus outbreaks reported to the National Outbreak Reporting System in the US. PubMedGoogle Scholar
  72. 72.
    Connolly MA, Communicable disease control in emergencies: a field manual. 2005: World Health Organization.Google Scholar
  73. 73.
    • Barclay L, Park GW, Vega E, Hall AJ, Parashar U, Vinjé J, et al. Infection control for norovirus. Clin Microb Infect. 2014;20:731–40. Reviews of infection prevention and control for norovirus. CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York (outside the USA) 2017

Authors and Affiliations

  1. 1.National Centre for Epidemiology and Population Health, Research School of Population HealthAustralian National UniversityCanberraAustralia
  2. 2.Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and PreventionAtlantaUSA

Personalised recommendations