Hospital Infection Control

Gastrointestinal tract infections

Gastrointestinal tract infections

  • Vascular Catheter-Related BSIs

  • Mechanical Circulating Support-Related BSIs

Gastroenteritis

  • Adenovirus (gastroenteritis)

  • Campylobacter species

  • Cholera

  • Clostridium difficile

  • Cryptosporidium species

  • Cyclospora infections

  • E. coli: Enterohemorrhagic 0157:H7; other species

  • Entamoeba histolytica (Amebiasis) enteritis

  • Giardia lamblia (Giardiasis)

  • Norovirus

  • Rotavirus

  • Salmonellosis (Salmonella species, typhoidal and non-typhoidal)

  • Shigellosis (Shigella species)

  • Vibrio parahemolyticus

  • Yersinia enterocolitica

What are the key principles of preventing gastrointestinal tract infections?

For all of these pathogens, transmission is primarily fecal-oral and strict adherence to standard precautions with emphasis on consistent adherence to hand washing measures is of primary importance. For incontinent and diapered patients, the use of contact precautions and the practice of cohorting infected patients can help further reduce transmission to other patients and to health care workers. Some of these infections can also be transmitted via aerosolization and this is discussed further where relevant.

General principles in preventing the transmission of Gastrointestinal Tract Infections in the hospital setting are:

  • Consistent, strict adherence to Standard Precautions in all situations, with emphasis on adherence to strict hand washing measures, and

  • In cases where incontinent or diapered patients are admitted to the hospital with diarrhea and/or vomiting of a possibly infectious etiology, these patients (adult and pediatric) should be immediately placed on Contact Precautions as the potential pathogens involved can be highly transmissible, pending diagnostic evaluation.

  • Personnel should also wear a mask when cleaning up vomitus due to the possibility of aerosolization of infectious viral particles associated with some types of viral gastroenteritis

  • Consideration should be given to cohorting infected patients for the duration of the illness to reduce the risk of transmission to other patients and to health care workers if private rooms are not available.

Recommendations for specific pathogens:

Gastroenteritis

  • Adenovirus (gastroenteritis): Standard Precautions; add Contact Precautions for incontinent or diapered patients including young children, with private room, wash hands with soap and water after removal of gown and gloves, and dedicate non-critical patient care equipment. Infective material: feces. Duration of precautions: for the duration of illness, or the duration of hospitalization. Special considerations: none.

  • Campylobacter species: Standard Precautions; add Contact Precautions for incontinent or diapered patients including young children, with private room, wash hands with soap and water after removal of gown and gloves, and dedicate non-critical patient care equipment. Infective material: feces. Duration of precautions: for the duration of illness, or the duration of hospitalization. Special considerations: reportable disease, contact local and State Health Departments.

  • Cholera: Standard Precautions; add Contact Precautions for incontinent or diapered patients including young children, with private room, wash hands with soap and water after removal of gown and gloves, and dedicate non-critical patient care equipment. Duration of precautions: for the duration of illness, or the duration of hospitalization. Special considerations: potential agent of bioterrorism, confirmed or suspected cases should be reported immediately to local and State Health Departments.

  • Clostridium difficile, antigen and/or cytotoxin positive with diarrhea: Standard Precautions and Contact Precautions with private room, wash hands with soap and water after removal of gown and gloves, and dedicate non-critical patient care equipment. Infective material: feces. Duration of precautions: until diarrhea is resolved. Some experts recommend extending contact precautions until hospital discharge in hospitals or units that have unacceptably high rates of C. difficile colitis despite implementation of basic prevention strategies. A follow-up negative toxin assay is not necessary and a test of cure is not recommended. Special considerations: Discontinue antibiotics, other than for treatment of C. difficile, if appropriate. Direct exposure to contaminated patient care items and high-touch surfaces have been implicated as possible sources of infection, but the transfer of C. difficile to the patient via the hands of healthcare workers is thought to be the most likely mechanism of exposure. Washing hands with soap and water is preferred to using waterless antiseptic handrubs because of lack of sporicidal activity of alcohol used in handrubs, but consistent glove use is likely of greater importance. Asymptomatic patients should not be retested following successful treatment for C. difficile infection, and attempts should not be made to decolonize asymptomatic carriers. An accelerated hydrogen peroxide cleaning and disinfecting product (for example, Oxivir) or a 1:10 dilution of sodium hypochlorite (household bleach) should be used to clean the patient's room daily and at the time of discharge. The bleach solution should have a contact time of at least 10 minutes. Routine environmental screening for C. difficile is not recommended. The utility of requiring family members and other visitors to wear gowns and gloves is unknown. At a minimum though, it is generally recommended that family members and visitors perform hand hygiene upon entering and leaving a patient's room.

  • Cryptosporidium species: Standard Precautions; add Contact Precautions for incontinent or diapered patients including young children, with private room, wash hands with soap and water after removal of gown and gloves, and dedicate non-critical patient care equipment. Infective material: feces. Duration of precautions: for the duration of illness, or the duration of hospitalization. Special considerations: reportable disease, contact local and State Health Departments.

  • Cyclospora infections: Standard Precautions; add Contact Precautions for incontinent or diapered patients including young children, with private room, wash hands with soap and water after removal of gown and gloves, and dedicate non-critical patient care equipment. Infective material: feces. Duration of precautions: for the duration of illness, or the duration of hospitalization. Special considerations: reportable disease, contact local and State Health Departments.

  • E. coli, Enterohemorrhagic 0157:H7 and other shiga-toxin producing strains: Standard Precautions; add Contact Precautions for incontinent or diapered patients including young children, with private room, wash hands with soap and water after removal of gown and gloves, and dedicate non-critical patient care equipment. Infective material: feces. Duration of precautions: for the duration of illness, or the duration of hospitalization. Special considerations: reportable disease, contact local and State Health Departments.

  • E. coli, other species: Standard Precautions; add Contact Precautions for incontinent or diapered patients including young children, with private room, wash hands with soap and water after removal of gown and gloves, and dedicate non-critical patient care equipment. Infective material: feces. Duration of precautions: for the duration of illness, or the duration of hospitalization. Special considerations: none.

  • Entamoeba histolytica (Amebiasis) enteritis: Standard Precautions; add Contact Precautions for incontinent or diapered patients including young children, with private room, wash hands with soap and water after removal of gown and gloves, and dedicate non-critical patient care equipment. Infective material: feces. Duration of precautions: for the duration of illness, or the duration of hospitalization. Special considerations: Person to person transmission is rare, though transmission in certain group settings has been reported.

  • Giardia lamblia (Giardiasis): Standard Precautions; add Contact Precautions for incontinent or diapered patients including young children, with private room, wash hands with soap and water after removal of gown and gloves, and dedicate non-critical patient care equipment. Infective material: feces. Duration of precautions: for the duration of illness, or the duration of hospitalization. Special considerations: reportable disease, contact local and State Health Departments.

  • Norovirus gastroenteritis: Standard Precautions; add Contact Precautions for incontinent or diapered patients including young children, with private room, wash hands with soap and water after removal of gown and gloves, and dedicate non-critical patient care equipment. Wear a mask when cleaning up vomitus. Infective material: feces, vomitus. Environmental and fomite contamination may act as a source of infection. Direct person-to-person spread may also play a role in transmission. Duration of precautions: 72 hours following last day of symptoms. Special considerations: Noroviruses are highly contagious, and as few as 10 viral particles may be enough to infect an individual. Wear a mask when cleaning up vomitus. Virus can become aerosolized, enter the oral mucosa and then be swallowed, resulting in infection. Health care workers with Norovirus gastroenteritis should not return to work until symptom-free for 72 hours. Ensure consistent environmental cleaning and disinfectiion, using an accelerated hydrogen peroxide product (for example, Oxivir) routinely. Cohorting infected patients (separate air spaces and toilet facilities) may help interrupt transmission during outbreaks. Outbreaks should be reported to local and State Health Departments.

  • Rotavirus: Standard Precautions; add Contact Precautions for incontinent or diapered patients including young children, with private room, wash hands with soap and water after removal of gown and gloves, and dedicate non-critical patient care equipment. Infective material: feces. Duration of precautions: for the duration of illness, or the duration of hospitalization. Special considerations: The virus can survive on hard surfaces, hands and in contaminated water for several days. Ensure consistent environmental cleaning and disinfection, and remove soiled diapers frequently. Rotavirus is relatively resistant to common disinfectants, but is inactivated by chlorine. Both immunocompetent and immunocompromised children and the elderly may shed the virus for prolonged periods of time. Immunocompromised patients can excrete virus for 30 days or more. Cohorting infected patients may help interrupt transmission during outbreaks.

  • Salmonellosis (all Salmonella species, typhoidal and non-typhoidal): Standard Precautions; add Contact Precautions for incontinent or diapered patients including young children, with private room, wash hands with soap and water after removal of gown and gloves, and dedicate non-critical patient care equipment. Infective material: feces. Duration of precautions: for the duration of illness, or the duration of hospitalization. Special considerations: reportable disease, contact local and State Health Departments.

  • Shigellosis (Shigella species): Standard Precautions; add Contact Precautions for incontinent or diapered patients including young children, with private room, wash hands with soap and water after removal of gown and gloves, and dedicate non-critical patient care equipment. Infective material: feces. Duration of precautions: for the duration of illness, or the duration of hospitalization. Special considerations: reportable disease, contact local and State Health Departments.

  • Vibrio parahemolyticus: Standard Precautions; add Contact Precautions for incontinent or diapered patients including young children, with private room, wash hands with soap and water after removal of gown and gloves, and dedicate non-critical patient care equipment. Infective material: feces. Duration of precautions: for the duration of illness, or the duration of hospitalization. Special considerations: reportable disease, contact local and State Health Departments.

  • Yersinia enterocolitica: Standard Precautions; add Contact Precautions for incontinent or diapered patients including young children, with private room, wash hands with soap and water after removal of gown and gloves, and dedicate non-critical patient care equipment. Infective material: feces. Duration of precautions: for the duration of illness, or the duration of hospitalization. Special considerations: reportable disease, contact local and State Health Departments.

Hepatitis A

  • Standard Precautions; add Contact Precautions for incontinent or diapered patients including young children, with private room, wash hands with soap and water after removal of gown and gloves, and dedicate non-critical patient care equipment. Infective material: feces. Duration of precautions: Maintain contact precautions in infants and children <3 years of age for duration of hospitalization; for children 3-14 years of age, maintain contact precautions for 2 weeks after onset of symptoms; for all others, maintain contact precautions for 1 week after the onset of symptoms. Special considerations: reportable disease, confirmed or suspected cases should be reported immediately to local and State Health Departments. Food handlers should be furloughed. Rules limiting eating and drinking on medical units must be strictly enforced.

What are the conclusions of clinical trials and meta-analyses regarding gastrointestinal tract infections?

There are few randomized clinical trials and meta-analyses evaluating the impact of infection control practices on gastrointestinal tract infections. The majority of data guiding infection control recommendations for gastrointestinal infections come from outbreak investigations (case-control studies) and prospective epidemiologic studies, environmental contamination studies, studies evaluating the impact of particular interventions on reducing transmission of specific pathogens and interrupting outbreaks, and studies of the efficacy of various disinfectants and decontamination processes on environmental contamination. See Table I for select references.

Table I.

Gastrointestinal Tract Infections
Pathogen Select References Notes
Clostridium difficile Boyce JM, 2006 Study showing lack of association between increasing use of alcohol-based hand rubs and increased incidence of C. difficile infections
Brooks SE, 1992 Prospective before/after trial, reduction in cases with switch to disposable thermometers
Gerding DN, 2010 Review article, treatment considerations and hospital epidemiology management strategies
Jernigan JA, 1998 Randomized cross-over study of disposable thermometers as prevention
Johnson S, 1990 Prospective controlled trial of glove use to interrupt nosocomial transmission
Loo VG, 2005 Institutional outbreak investigation virulent strain
Mayfield JL, 2000 Environmental controls to reduce transmission
McDonald LC, 2005 Identification of new hypervirulent epidemic strain
McFarland LV, 1989 Nosocomial acquisition
Riggs MM, 2007 Shedding of C. difficile after resolution diarrhea
Sethi AK, 2010 Study showing 56% patients with asymptomatic carriage and prolonged environmental shedding 1-4 weeks after effective treatment for C difficile infection
Sohn S, 2005 Varying rates among hospitals
Warny M, 2005 Outbreaks associated with an emerging strain
Wilcox MH, 2003 Detergent versus hypochlorite on environmental contamination
Cryptosporidium species Bruce BB, 2000 Nosocomial transmission
Entamoeba histolytica (Amebiasis) enteritis Vreden SG, 2000 Outbreak among household contacts
Norovirus Barker J, 2004 Effects of cleaning and disinfection
Chadwick PR, 1994 Hospital outbreak of viral gastroenteritis, transmission associated with vomiting
Cheesbrough JS, 2000 Environmental contamination associated with prolonged outbreak in hotel
Marks PJ, 2000 Airborne transmission in hotel restaurant
Marks PJ, 2003 Airborne transmission in school outbreak
Marx A, 1999 Outbreak in long term care facility, study of transmission, use of epidemiologic and molecular methods
Widdowson MA, 2002 Large scale outbreak of gastroenteritis on cruise ships
Wu HM, 2005 Outbreak at long term care facility
Rotavirus Barnes GL, 2003 Healthcare workers as source for nosocomial cases, specific serotype associated with new infection and effect of infection control interventions
Cunliffe NA, 2007 Rotavirus as a cause of healthcare-associated gastroenteritisin pediatric hospital
Mori I, 2002 Chronic shedding of rotavirus
Prince DS, 1986 Aerosol transmission
Ratner AJ, 2001 Nosocomial outbreak in pediatric hospital
Hepatitis A Doebbeling BN, 1993 Outbreak of hepatitis A among health care workers
Jensenius M, 1998 Outbreak of hepatitis A and effect of infection control interventions
Rosenblum LS, 1991 NICU outbreak, prolonged shedding

What are the consequences of ignoring gastrointestinal tract infection prevention?

The consequences of ignoring key concepts related to the control of gastrointestinal tract infections are widely illustrated in the literature, particularly through case-control studies and case series of outbreaks of a variety of gastrointestinal infections resulting from poor adherence to infection control practices, affecting patients and health care workers. For example, there are several reports of outbreaks of acute Hepatitis A infection among neonates and health care workers in neonatal ICUs linked to inconsistent hand hygiene practices and eating and drinking on medical units.

Further support for the effectiveness of many infection control measures in limiting the transmission of gastrointestinal infections comes from studies demonstrating successful interruption of outbreaks through the implementation of simple, specific infection control interventions, including education and reinforcement of accepted practices, particularly strict adherence to good hand hygiene. (See Table I for select references.) Furthermore, the gastrointestinal tract is a reservoir for many nosocomial pathogens, including for example Enterococcus species such as VRE, drug resistant Enterobacteriaciae and Candida species. There may be potential, then, for dissemination of these nosocomial pathogens in the health care environment when infection control measures are not implemented for patients with fecal incontinence or diarrhea.

What other information supports the conclusions of studies on gastrointestinal tract infections, e.g., case-control studies and case series?

The majority of data guiding infection control recommendations for gastrointestinal infections come from outbreak investigations (case-control studies) and prospective epidemiologic studies, environmental contamination studies, studies evaluating the impact of particular interventions on reducing transmission of specific pathogens and interrupting outbreaks, and studies of the efficacy of various disinfectants and decontamination processes on environmental contamination. For all of these pathogens, transmission is primarily fecal-oral, and the general principles that strict adherence to standard precautions with emphasis on consistent adherence to hand washing measures is of primary importance, and the use of contact precautions and the practice of cohorting infected patients to help further reduce transmission to other patients and to health care workers is well supported. The findings from select studies pertaining to specific pathogens are summarized in the tables below.

Clostridium difficile deserves special mention as the most common cause of health-care associated diarrhea, and numerous studies in a variety of settings have demonstrated the ability to interrupt outbreaks with the use of appropriate infection control measures and environmental decontamination. Environmental contamination by C. difficile is well documented, and though the environment is an unlikely primary source of infection, direct exposure to contaminated patient care items and high-touch surfaces have been implicated as possible sources of infection. However, studies suggest that the transfer of C. difficile to the patient via the hands of healthcare workers is the most likely mechanism of exposure, and consistent use of gloves is extremely important in preventing nosocomial transmission.

In addition, washing hands with soap and water is generally preferred to using waterless antiseptic handrubs because of lack of sporicidal activity of alcohol used in handrubs; however, consistent glove use is likely of greater importance. The rationale behind dedicating non-critical patient care equipment comes in part from studies showing a significant reduction in rates of nosocomial C difficile diarrhea by using single-use, disposable thermometers as compared to electronic thermometers. Because C. difficile is a spore-forming organism, the use of traditional disinfectants has been found to be ineffective and the practice of cleaning and disinfecting patient's rooms daily and at the time of discharge with an accelerated hydrogen peroxide product or a 1:10 dilution of sodium hypochlorite (household bleach) has been shown to be important in preventing transmission of C. difficile. See table below for select references.

Summary of current controversies.

In general, the practices outlined are widely accepted as standard practice in reducing the transmission of Gastrointestinal Tract Infections. One area of controversy, however, pertains to the recommended duration of contact precautions for patients with asymptomatic shedding of C. difficile. The Centers for Disease Control and Prevention currently recommends contact precautions for the duration of illness, but some experts recommend continuing precautions for a more prolonged period, at least 48 hours after diarrhea resolves. Asymptomatically colonized patients who continue to shed C. difficile spores generally shed a much lower number of spores and the degree of contamination is not as great as for symptomatic patients with active C. difficile colitis and there is no data to support continued isolation of asymptomatic patients as part of routine infection control efforts. However, some experts recommend prolonging contact precautions for patients with asymptomatic C difficile colonization when there are concerns for ongoing transmission or unacceptably high rates of C. difficile colitis, given data showing persistence of skin contamination and environmental shedding during and after treatment if C. difficile infection.

There is also some controversy surrounding the recommendation to preferentially use hand washing with soap and water over alcohol-based hand rubs for hand hygiene. Although alcohol-based hand rubs lack sporicidal activity against C. difficile spores, hand hygiene compliance is usually greater with the use of hand rubs for a variety of reasons, sinks are sometimes not conveniently available in all health care settings, and there is data showing a lack of association between increased use of hand rubs and an increased incidence of C. difficile infections.

What is the impact of gastrointestinal tract infections relative to infections at other sites or from other specific pathogens?

The gastrointestinal tract is a reservoir for many nosocomial pathogens, including for example Enterococcus species such as VRE, drug resistant Enterobacteriaciae and Candida species. There is serious potential, then, for dissemination of these nosocomial pathogens in the health care environment, potentially affecting patients and health care personnel, when infection control measures are not implemented for colonized or infected patients with fecal incontinence or diarrhea.

Overview of important clinical trials, meta-analyses, case control studies, case series, and individual case reports related to infection control and gastrointestinal tract infections.

Table I provides a summary of the research surrounding gastrointestinal tract infections.

What national and international gastrointestinal tract infection guidelines exist?

CDC Guidelines

Siegel JD, Rhinehart E, Jackson M, Chiarello L, and the Healthcare Infection Control Practices Advisory Committee, 2007 Guideline for Isolation Precatutions: Preventing Transmission of Infectious Agents in Healthcare Settings.

Sehulster L, Chinn R. Guidelines for Environmental Infection Control in Health-Care Facilities. Recommendations of the CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC). MMWR Morb Mortal Wkly Rep 2003;52(RR10):1-42.

Other US Guidelines: SHEA (Society of Healthcare Epidemiology of America), IDSA (Infectious Diseases Society of America)

Cohen SH, Gerding DN, Johnson S, Kelly CP, Loo VG, McDonald LC, Pepin J, Wilcox MH. Clinical Practice Guidelines for Clostridium difficile Infection in Adults: 2010 Update by the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA). Infect Control Hosp Epidemiol, 2010 May;31(5):431-455.

Dubberke ER, Gerding DN, Classen D, Arias KM, Podorny K, Anderson DJ, Burstin H, Caifee DP, Coffin SE, Fraser V, Griffin FA, gross P, Kaye KS, Klompas M, Lo E, Marschall J, mermel LA, Nicolle L, Pegues DA, Perl TM, Saint S, Salgado CD, Weinstein RA, Wise R, Yokoe DS. Strategies to prevent Clostridium difficile infections in acute care hospitals. Infect Control Hosp Epidemiol 2008 Oct; 29 Suppl 1:S81-92.

References

General:

Donskey CJ. The role of the intestinal tract as a reservoir and source for transmission of nosocomial pathogens. Clin Infect Dis 2004;39(2):219-26.

Evans MR, Meldrum R, Lane W, et al. An outbreak of viral gastroenteritis following environmental contamination at a concert hall. Epidemiol Infect 2002;129(2):355-60.Musher DM,

Musher BL. Contagious Acute Gastrointestinal Infections. N Engl J Med 2004;351:2417-27.

Roy CJ, Milton DK. Airborne transmission of communicable infection—the elusive pathway. N Engl J Med 2004;350(17):1710-2.

Clostridium difficile:

Boyce JM, Ligi C, Kohan C, Dumigan D, Havill NL. Lack of association between the increased incidence of Clostridium difficile-associated disease and the increasing use of alcohol-based hand rubs. Infect Control Hosp Epidemiol 2006;27(5):479-483.

Brooks SE, Veal RO, Kramer M, Dore L, Schupf N, adachi M. Reduction in the incidence of Clostridium difficile-associated diarrhea in an acute care hospital and a skilled nursing facility following replacement of electronic thermometers with single-use disposables. Infect Control Hosp Epidemiol 1992;13(2):98-103.

Gerding DN, Johnson S. Management of Clostridium difficile Infection: Thinking Inside and Outside the Box. Clin Infect Dis 2010;51(11):1306-13.

Jernigan JA, Siegman-Igra Y, Guerrant RC, Farr BM. A randomized crossover study of disposable thermometers for prevention of Clostridium difficile and other nosocomial infections. Infect Control Hosp Epidemiol 1998;19(7):494-9.

Johnson S, Gerding DN, Olson MM, et al. Prospective, controlled study of vinyl glove use to interrupt Clostridium difficile nosocomial transmission. Am J Med 1990;88(2):137-40.

Loo VG, Poirer L, Miller MA, et al. A predominantly clonal multi-institutional outbreak of Clostridium difficile-associated diarrhea with high morbidity and mortality. N Engl J Med 2005; 353(23):2442-9.

Mayfield JL, Leet T, Miller J, Mundy LM. Environmental control to reduce transmission of Clostridium difficile. Clin Infect Dis 2000;31(4):995-1000.

McDonald LC, Kilgore GE, Thompson A, et al. An epidemic, toxin gene-variant strain of Clostridium difficile. N Engl J Med. 2005;353(23):2433-41.

McFarland LV, Mulligan ME, Kwok RY, Stamm WE. Nosocomial acquisition of Clostridium difficile infection. N Engl J Med 1989;320(4):204-10.

Riggs MM, Sethi AK, Zabarsky TF, et al. Asymptomatic carriers are a potential source for transmission of epidemic and nonepidemic strains of Clostridium difficile strains among long-term care facility residents. Clin Infect Dis 2007;45:992-998.

Sethi AK, Al-Nassir WN, Nerandzie BS, et al. Persistence of skin contamination and environmental shedding of Clostridium difficile during and after treatment of C. difficile infection. Infect Control Hosp Epidemiol 2010;31(1):21-27.

Sohn S, Climo M, Diekema D, et al. Varying rates of Clostridium difficile-associated diarrhea at prevention epicenter hospitals. Infect Control Hosp Epidemiol 2005;26(8):676-9.

Warny M, Pepin J, Fang A, et al. Toxin production by an emerging strain of Clostridium difficile associated outbreaks of severe disease in North America and Europe. Lancet 2005;366(9491):1079-84.

Wilcox MH, Fawley WN, Wigglesworth N, Parnell P, Verity P, Freeman J. Comparison of the effect of detergent versus hypochlorite cleaning on environmental contamination and the incidence of Clostridium difficile infection. J Hosp Infect 2003;54(2):109-14.

Cryptosporidium species:

Bruce BB, Blass MA, Blumberg HM, Lennox JL, del Rio C, Horsburgh CR, Jr.. Risk of Cryptosporidium parvum transmission between hospital roommates. Clin Infect Dis 2000;31(4):947-50.

Entamoeba histolytica (Amebiasis) enteritis:

Vreden SG, Visser LG, Verweij JJ, et al. Outbreak of amebiasis in a family in the Netherlands. Clin Infect Dis 2000;31(4):1101-4.

Norovirus:

Barker J, Vipond IB, Bloomfield SF. Effects of cleaning and disinfection in reducing the spread of norovirus contamination via environmental surfaces. J Hosp Infect 2004;58(1):42-9.

Chadwick PR, McCann R. Transmission of a small round structured virus by vomiting during a hospital outbreak of gastroenteritis. J Hosp Infect 1994;26(4):251-9.

Cheesbrough JS, Green J, Gallimore CI, Wright PA, Brown DW. Widespread environmental contamination with Norwalk-like viruses (NLV) detected in a prolonged hotel outbreak of gastroenteritis. Epidemiol Infect 2000; 125(1):93-8.

Marks PJ, Vipond IB, Carlisle D, Deakin D, Fey RE, Caul EO. Evidence for airborne transmission of Norwalk-like virus (NLV) in a hotel restaurant. Epidemiol Infect 2000;124(3):481-7.

Marks PJ, Vipond IB, Regan FM, Wedgwood K, Fey RE, Caul EO. A school outbreak of Norwalk-like virus: evidence for airborne transmission. Epidemiol Infect 2003;131(1):727-36.

Marx A, Shay DK, Noel JS, et al. An outbreak of acute gastroenteritis in a geriatric long-term-care facility: combined application of epidemiological and molecular diagnostic methods. Infect Control Hosp Epidemiol. 1999;20(5):306-11.

Widdowson MA, Cramer EH, Hadley L, et al. Outbreaks of acute gastroenteritis on cruise ships and on land: identification of a predominant circulating strain of norovirus—United States 2002. J Infect Dis 2004;190(1):27-36.

Wu HM, Fornek M, Kellogg JS, et al. A norovirus outbreak at a long term-care facility: the role of environmental surface contamination. Infect Control Hosp Epidemiol 2005;26(10):802-10.

Rotavirus:

Barnes GL, Callaghan SL, Kirkwood CD, Bogdanovic-Sakran N, Johnston LJ, Bishop RF. Excretion of serotype G1 rotavirus strains by asymptomatic staff: a possible source for nosocomial infection. J Pediatr 2003;142(6):722-5.

Cunliffe NA, Allan C, Lowe SJ, et al. Health-care associated rotavirus gastroenteritis in a large pediatric hospital in the UK. J Hosp Infect. 2007;67(3):240-4.

Mori I, Matsumoto K, Sugimoto K, et al. Prolonged shedding of rotavirus in a geriatric inpatient. J Med Virol 2002;67(4):613-5.

Prince DS, Astry C, Vonderfecht S, Jakab G, Shern FM, Yolken RH. Aerosol transmission of experimental rotavirus infection. Pediatr Infect Dis 1986;5(2):218-22.

Ratner AJ, Neu N, Jakob K, et al. Nosocomial rotavirus infection in a pediatric hospital. Infect Control Hosp Epidemiol 2001;22(5):299-301.

Hepatitis A:

Doebbeling BN, Li N, Wenzel RP. An outbreak of hepatitis A among health care workers: risk factors for transmission. Am J Public Health. 1993;83(12):1664-5.

Jensenius M, Ringertz SH, Berlid D, Bell H, Espinoza R, Grinde B. Prolonged nosocomial outbreak of hepatitis A arising from an alcoholic with pneumonia. Scand J Infect Dis 1998;30(2):119-23.

Rosenblum LS, Villarino ME, Nainan OV, et al. Hepatitis A outbreak in a neonatal intensive care unit: risk factors for transmission and evidence of prolonged shedding by preterm infants. J Infect Dis 1991;164(3):476-82.

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