Vital Signs: Foodborne Norovirus Outbreaks — United States, 2009–2012

Aron J. Hall, DVM; Mary E. Wikswo, MPH; Kimberly Pringle, MD; L. Hannah Gould, PhD; Umesh D. Parashar, MBBS


Morbidity and Mortality Weekly Report. 2014;63(22):491-495. 

In This Article


During 2009–2012, a total of 4,318 norovirus outbreaks were reported to NORS, resulting in 161,253 illnesses, 2,512 hospitalizations, and 304 deaths. Foodborne transmission was the primary mode reported in 1,008 (23%) norovirus outbreaks, representing 48% of the 2,098 foodborne outbreaks reported with a single suspected or confirmed cause during the 4-year study period. Other primary transmission modes reported among the 4,318 norovirus outbreaks included person-to-person (2,976 [69%]), environmental (15 [0.35%]), waterborne (11 [0.26%]), and unknown transmission mode (308 [7%]). In 158 (16%) of foodborne norovirus outbreaks, secondary transmission through one of these other modes was reported. Norovirus outbreaks were most common in winter, with 2,394 (55%) occurring during December–February (Figure 1). Among foodborne norovirus outbreaks, 398 (39%) occurred during December–February, compared with 1,996 (60%) of nonfoodborne norovirus outbreaks.

Figure 1.

Number of reported norovirus outbreaks, by primary transmission mode and month of onset — National Outbreak Reporting System, United States, 2009–2012
* Includes person-to-person, waterborne, environmental contamination, and other or unknown transmission modes.

Of the 4,318 reported norovirus outbreaks, 2,961 (69%) were laboratory-confirmed, and 1,357 (31%) were suspected to be caused by norovirus based on clinical or epidemiologic findings. Of confirmed norovirus outbreaks, a genogroup was identified in 2,729 (92%), including 2,341 (86%) GII, 374 (14%) GI, 13 (0.5%) mixed GI/GII, and one (0.04%) GIV. A specific norovirus genotype was reported in 707 (24%) of the laboratory-confirmed outbreaks, among which GII.4 (465 [66%]) was predominant, followed by GII.1 (58 [8%]) and GI.6 (56 [8%]). Foodborne outbreaks were more often caused by non-GII.4 genotypes (48%) than were nonfoodborne outbreaks (31%, p<0.001).

Foodborne norovirus outbreaks were reported by 43 states (Figure 2), with the number per state ranging from one to 117 (median = nine). The median number of outbreaks per 1,000,000 person-years reported among the states was 0.6 (range = 0.05–5.5). Of 1,008 foodborne norovirus outbreaks, a setting of food preparation was reported for 904 (90%), among which restaurants (574 [64%]) and catering or banquet facilities (151 [17%]) were most common ( Table 1 ). In contrast, most (80%) nonfoodborne outbreaks occurred in long-term care facilities such as nursing homes.

Figure 2.

Number and rate of reported foodborne norovirus outbreaks (per 1 million person-years*), by state — National Outbreak Reporting System, United States, 2009–2012
* Legend indicates rate ranges divided by quartile.

Demographic characteristics and outcomes of outbreak-associated illnesses reflected the settings in which outbreaks occurred ( Table 2 ). Foodborne outbreaks more often affected men (44%) and persons aged <75 years (95%), compared with nonfoodborne outbreaks (30% men and 50% aged <75 years, both p<0.001). Likewise, the reported case-hospitalization and case-fatality ratios in foodborne outbreaks (1% and 0.01%, respectively) were lower than those in nonfoodborne outbreaks (2% and 0.3%, respectively, both p<0.001), However, a greater proportion of cases among foodborne outbreaks resulted in emergency department visits than among nonfoodborne outbreaks (4% versus 2%, p<0.001). Foodborne outbreaks also had significantly fewer reported cases (median: 12 per outbreak) compared with nonfoodborne outbreaks (median: 30 per outbreak, p<0.001).

Factors contributing to food contamination were reported in 520 (52%) of 1,008 foodborne norovirus outbreaks, among which infectious food workers were implicated as the source of contamination in 364 (70%). Bare-hand contact with ready-to-eat foods was explicitly identified in 196 (54%) of these outbreaks.

At least one specific food item was implicated in 324 (32%) of 1,008 foodborne norovirus outbreaks; among those outbreaks with data, 92% of implicated foods were contaminated during preparation, and 75% were foods eaten raw (i.e., not cooked). Of 324 outbreaks with an implicated food, only 67 (21%) could be attributed to a single food category; those attributed most often were vegetable row crops (e.g., lettuce and other leafy vegetables) (20 [30%]), fruits (15 [21%]), and mollusks (13 [19%]).