Abstract
Norovirus-associated AGE in children <11 years resulted in substantial AGE illness among household contacts (HHCs). Vomiting (≥5 episodes in 24 hours) was the greatest risk factor (aOR, 2.85, [95% CI, 1.91-4.26]) for AGE symptoms among HHCs of norovirus-positive index cases. HHCs age 0-4 years had the highest attack rates (22%).
Keywords: Norovirus, acute gastroenteritis, household transmission
summary:
Households of children with norovirus-positive acute gastroenteritis (AGE) have more AGE illness among household contacts than households of children with norovirus-negative AGE. Children <5 years are important contributors to AGE spread and frequent vomiting episodes increases risk of transmission.
Introduction
In the United States (U.S.), norovirus is estimated to cause 19-21 million illnesses annually, with about 10% of cases seeking medical care and an estimated total economic burden of over $10 billion (1, 2). Since the introduction of rotavirus vaccination in the U.S. in 2006, norovirus has become the leading cause of severe acute gastroenteritis (AGE) among children <5 years of age, and this age group accounts for a greater proportion of norovirus heath care visits (1, 3).
Norovirus illness is characterized by sudden onset of vomiting, diarrhea, and/or fever. Symptoms usually begin 12-48 hours following exposure and last 1-3 days (4). Norovirus is highly contagious, with a small infectious dose and high viral shedding even in asymptomatic individuals. Norovirus can spread by fecal-oral transmission, aerosolized vomitus, contaminated food or water, and environmental surfaces. Norovirus remains infectious on surfaces for up to two weeks and may be resistant to common disinfectants (5).
A recent U.S. study of medically attended AGE (MAAGE) cases and their household contacts (HHCs) found a norovirus secondary attack rate of 30% (6). Other norovirus household transmission studies have reported secondary attack rates of 15-33% (7–10). We utilized data from a U.S. pediatric surveillance system to identify children seeking care for AGE and obtained follow-up data from their HHCs to evaluate household transmission. A previous study used this dataset to compare AGE in households of rotavirus-positive or rotavirus-negative children with AGE and found 35% households and 16% of HHCs of a rotavirus-positive child to have AGE illness (11). In this study, we compared the prevalence of AGE in HHCs of norovirus-positive and negative index cases and identified risk factors associated with norovirus household transmission.
Methods
Children >14 days and <11 years old with AGE who were hospitalized or seen in the emergency department of participating New Vaccine Surveillance Network (NVSN) between December 1, 2011 and June 30, 2016 were eligible for enrollment (11). Written consent and interviews were collected as previously described (11). The NVSN study was reviewed and approved by the Institutional Review Boards of the US Centers for Disease Control and Prevention (CDC) and each participating site.
Households that did not complete the follow-up survey 7-35 days after enrollment were excluded. Enrolled children were excluded if they were missing a stool specimen, norovirus test result, complete clinical severity score (modified Vesikari severity score (11)), or complete HHC information from the enrollment or follow-up survey. To be included in the analysis, the NVSN-enrolled child had to be the index case, meaning 1) no AGE symptoms existed among HHCs in the week prior to enrollment and 2) HHCs and the enrolled child did not share the same symptom onset date. To be classified as a transmission household, the first HHC with AGE symptoms had to occur 1-7 days following the index child’s symptom onset. Households where the first AGE symptoms occurred >7 days following the symptom onset of the index child were excluded, as these illnesses may have resulted from an alternate exposure. HHCs were considered ill if their AGE symptoms began 1-7 days after the index case or another ill HHC. If no HHCs were ill during the follow-up period, the household was considered a non-transmission household (Appendix 1).
Whole stool specimens or fecal material eluted from diapers were collected from enrolled participants within 10 days of AGE onset. Specimens were tested for norovirus at NVSN sites or the CDC using reverse transcription-polymerase chain reaction (RT-PCR), xTAG GPP (Luminex Corporation, Toronto, Canada), or FilmArray GI Panel (BioFire Diagnostics Inc, Salt Lake City, UT, USA) (3). Statistical analyses were performed as described in Wikswo et al. (11), with comparisons by norovirus result rather than rotavirus result. Mixed-effects models with a random effect to account for household clusters were used to calculate odds ratios (OR).
Results
Description of Participants
Of the 8,951 index cases, 1,984 (22%) tested norovirus-positive and 6,967 (78%) norovirus-negative. Compared to norovirus-negative children, norovirus-positive children were younger, more likely to be Hispanic, and from smaller households or households without other children. Norovirus positivity varied significantly by study site and surveillance year (Appendix 2).
Description of Household Follow-Up
The follow-up survey identified 6,342 HHCs of norovirus-positive index cases, and 23,461 HHCs of norovirus-negative index cases. A greater proportion of households of norovirus-positive index cases had ≥1 HHC with AGE compared to households of norovirus-negative index cases (32.6% vs 15.4%, respectively), (OR, 2.66, [95% CI, 2.37-2.98], p<0.0001). A greater proportion of HHCs of norovirus-positive index cases reported AGE symptoms compared to HHCs of norovirus-negative index cases (16.7% vs 6.2%), (OR, 3.02 [95% CI, 2.69-3.39], p <0.0001).
Over 60% of ill HHCs of norovirus-positive index cases were adults (18-49 years), while nearly 50% of ill HHCs of norovirus-negative index cases were children (0-17 years) (p<0.0001). Medical care was sought by 17.6% of ill HHCs of norovirus-positive index cases compared to 27.5% of ill HHCs of norovirus-negative index cases (p=0.0063).
Risk Factors for AGE among HHCs of Norovirus-Positive Index Cases
Based on the univariate analyses, household size and income, HHC age and sex, and index case race and ethnicity, age, vomiting, symptom duration, diaper use, daycare attendance, and study site were included in the multivariate analysis. The index case having ≥5 vomiting episodes in 24 hours was associated with the greatest odds of HHC transmission (aOR, 2.85 [95% CI 1.91-4.26]). HHCs age 0-4 years were at the greatest risk of reporting AGE symptoms (aOR, 1.76 [95% CI 1.41-2.18). Household income and size, HHC sex, index case race and ethnicity, and study site remained significant risk factors (Table 1).
Table 1.
Risk Factors for Reported AGE Symptoms in HHCs of Norovirus-Positive Subjects (N=6,342)
| Univariate Analysis | Multivariate Analysis | ||||||||
|---|---|---|---|---|---|---|---|---|---|
| Characteristic | Ill HHC No. | Total HHC No. | Attack Rate (%) | OR | 95% CI | P | OR | 95% CI | P |
| Households | |||||||||
| Size | |||||||||
| 2 or 3 people | 287 | 1,195 | 24.0% | 2.00 | 1.61-2.48 | <0.0001 | 1.79 | 1.40-2.25 | <0.0001 |
| 4 people | 312 | 1,797 | 17.4% | 1.33 | 1.06-1.65 | 0.0118 | 1.25 | 0.99-1.58 | 0.059 |
| ≥ 5 people | 458 | 3,350 | 13.7% | Ref | Ref | ||||
| Number of other children | |||||||||
| 0 | 321 | 1,493 | 21.5% | 1.75 | 1.39-2.20 | <0.0001 | |||
| 1 | 387 | 2,273 | 17.0% | 1.31 | 1.04-1.64 | 0.0194 | |||
| ≥ 2 | 349 | 2,576 | 13.6% | Ref | |||||
| Children wearing diapers | |||||||||
| No | 807 | 4,844 | 16.7% | Ref | |||||
| Yes | 250 | 1,493 | 16.7% | 1.01 | 0.81-1.25 | 0.9566 | |||
| Household income | |||||||||
| ≤ $25,000 | 422 | 3,113 | 13.6% | Ref | Ref | ||||
| $25,001-$50,000 | 216 | 1,247 | 17.3% | 1.34 | 1.04-1.71 | 0.0221 | 1.25 | 0.97-1.62 | 0.0846 |
| > $50,000 | 280 | 941 | 29.8% | 2.70 | 2.11-3.45 | <0.0001 | 1.89 | 1.42-2.51 | <0.0001 |
| Unknown/Refused | 139 | 1,041 | 13.6% | 0.98 | 0.75-1.29 | 0.9 | 0.97 | 0.73-1.28 | 0.8118 |
| HHCs | |||||||||
| Age | |||||||||
| 0-4 years | 155 | 707 | 21.9% | 1.39 | 1.14-1.70 | 0.0011 | 1.76 | 1.41-2.18 | <0.0001 |
| 5-17 years | 203 | 1,417 | 14.3% | 0.83 | 0.69-1.00 | 0.0443 | 1.09 | 0.90-1.32 | 0.3613 |
| 18-49 years | 645 | 3,845 | 16.8% | Ref | Ref | ||||
| ≥ 50 years | 54 | 373 | 14.5% | 0.84 | 0.61-1.16 | 0.2863 | 0.94 | 0.68-1.30 | 0.7012 |
| Sex | |||||||||
| Male | 414 | 2,765 | 15.0% | Ref | Ref | ||||
| Female | 643 | 3,577 | 18.0% | 1.24 | 1.10-1.41 | 0.0004 | 1.27 | 1.12-1.45 | 0.0003 |
| Enrolled subjects with AGE (index cases) | |||||||||
| Race/Ethnicity | |||||||||
| White Non-Hispanic | 299 | 1,133 | 26.4% | 2.54 | 2.01-3.23 | <0.0001 | 1.58 | 1.20-2.10 | 0.0014 |
| Black Non-Hispanic | 246 | 1,450 | 17.0% | 1.45 | 1.15-1.82 | 0.0015 | 1.23 | 0.95-1.60 | 0.1156 |
| Other Non-Hispanic | 116 | 546 | 21.3% | 1.91 | 1.38-2.66 | <0.0001 | 1.46 | 1.04-2.05 | 0.0304 |
| Hispanic | 396 | 3,205 | 12.4% | Ref | Ref | ||||
| Unknown | 0 | 8 | 0.0% | ||||||
| Age | |||||||||
| 0-11 months | 327 | 1,807 | 18.1% | 1.39 | 1.05-1.85 | 0.0231 | 1.39 | 0.89-2.16 | 0.1481 |
| 1 year | 326 | 1,939 | 16.8% | 1.27 | 0.96-1.68 | 0.0909 | 1.24 | 0.79-1.93 | 0.3459 |
| 2-4 years | 245 | 1,437 | 17.1% | 1.29 | 0.96-1.74 | 0.0906 | 1.28 | 0.88-1.86 | 0.193 |
| 5-10 years | 159 | 1,159 | 13.7% | Ref | Ref | ||||
| Max Vomiting Episodes in 24 hours | |||||||||
| 0-1 episode | 55 | 600 | 9.2% | Ref | Ref | ||||
| 2-4 episodes | 212 | 1,951 | 10.9% | 1.21 | 0.80-1.83 | 0.3756 | 1.30 | 0.85-1.99 | 0.2278 |
| ≥5 episodes | 790 | 3.791 | 20.8% | 2.61 | 1.78-3.85 | <0.0001 | 2.85 | 1.91-4.26 | <0.0001 |
| Diarrhea Episodes in 24 hours | |||||||||
| None | 377 | 2,286 | 16.5% | Ref | |||||
| Any | 680 | 4,056 | 16.8% | 1.02 | 0.84-1.23 | 0.839 | |||
| Duration of Symptoms ≥4 days | |||||||||
| No | 399 | 2,584 | 15.4% | Ref | Ref | ||||
| Yes | 658 | 3,758 | 17.5% | 1.16 | 0.96-1.40 | 0.1194 | 1.18 | 0.97-1.44 | 0.0977 |
| Child in Diaper | |||||||||
| No | 247 | 1,749 | 14.2% | Ref | Ref | ||||
| Yes | 810 | 4,585 | 17.7% | 1.30 | 1.06-1.61 | 0.0136 | 1.22 | 0.86-1.73 | 0.2721 |
| Child in Daycare | |||||||||
| No | 620 | 3,952 | 15.7% | Ref | Ref | ||||
| Yes | 437 | 2,387 | 18.3% | 1.20 | 1.00-1.45 | 0.05 | 1.13 | 0.90-1.41 | 0.3004 |
| Modified Vesikari Score | |||||||||
| 0-10 (mild) | 655 | 3,905 | 16.8% | Ref | |||||
| 11-15 (moderate) | 355 | 2,155 | 16.5% | 0.98 | 0.80-1.20 | 0.8319 | |||
| ≥ 16 (severe) | 47 | 282 | 16.7% | 0.99 | 0.64-1.53 | 0.9723 | |||
| Study Site | |||||||||
| Vanderbilt | 161 | 1,104 | 14.6% | 1.24 | 0.90-1.70 | 0.1949 | 1.09 | 0.79-1.51 | 0.5895 |
| Rochester | 65 | 419 | 15.5% | 1.33 | 0.87-2.03 | 0.186 | 0.94 | 0.60-1.47 | 0.7716 |
| Cincinnati | 98 | 420 | 23.3% | 2.2 | 1.50-3.24 | <0.0001 | 1.57 | 1.04-2.38 | 0.0314 |
| Seattle | 153 | 505 | 30.3% | 3.15 | 2.20-4.50 | <0.0001 | 2.15 | 1.46-3.15 | 0.0001 |
| Houston | 161 | 1,327 | 12.1% | Ref | Ref | ||||
| Kansas City | 242 | 1,393 | 17.4% | 1.52 | 1.13-2.05 | 0.0059 | 1.32 | 0.97-1.80 | 0.0777 |
| Oakland | 177 | 1,174 | 15.1% | 1.29 | 0.94-1.76 | 0.1158 | 1.39 | 1.01-1.92 | 0.0431 |
| Surveillance Year | |||||||||
| Dec 2011 – Nov 2012 | 165 | 1,041 | 15.9% | 0.92 | 0.68-1.24 | 0.5704 | |||
| Dec 2012 – Nov 2013 | 235 | 1,299 | 18.1% | 1.07 | 0.82-1.41 | 0.5992 | |||
| Dec 2013 – Nov 2014 | 267 | 1,566 | 17.1% | Ref | |||||
| Dec 2014 – Nov 2015 | 221 | 1,499 | 14.7% | 0.84 | 0.64-1.10 | 0.2041 | |||
| Dec 2015 – June 2016 | 169 | 937 | 18.0% | 1.07 | 0.80-1.43 | 0.6448 | |||
Risk Factors for AGE Illness in Households of Norovirus-Positive Index Cases
The multivariate analysis assessing transmission in households of norovirus-positive index cases included other children in the house in diapers, household income, index case race and ethnicity, age, vomiting, symptom duration, diaper use, daycare attendance, study site, and study year. The index case having ≥5 vomiting episodes in 24 hours was associated with the greatest odds of ≥1 HHC reporting AGE symptoms (aOR, 2.99 [95% CI 2.01-4.43]). Household income, other children in the house in diapers, index case race and ethnicity, index child symptom duration, and study site and year were also associated with an increased odds of household transmission (Table 2).
Table 2.
Risk Factors for Reported AGE Symptoms in Households of Norovirus-Positive Subjects (N=1,984).
| Univariate Analysis | Multivariate Analysis | ||||||||
|---|---|---|---|---|---|---|---|---|---|
| Characteristic | Ill Households No. | Total Households No. | Attack Rate (%) | OR | 95% CI | P | OR | 95% CI | P |
| Households | |||||||||
| Size | |||||||||
| 2 or 3 people | 216 | 681 | 31.7% | 0.96 | 0.76-1.20 | 0.7045 | |||
| 4 people | 200 | 599 | 33.4% | 1.03 | 0.82-1.30 | 0.7834 | |||
| ≥ 5 people | 230 | 704 | 32.7% | Ref | |||||
| Number of other children | |||||||||
| 0 | 226 | 709 | 31.9% | 0.97 | 0.76-1.22 | 0.778 | |||
| 1 | 237 | 714 | 33.2% | 1.03 | 0.81-1.30 | 0.8289 | |||
| ≥ 2 | 183 | 561 | 32.6% | Ref | |||||
| Children wearing diapers | |||||||||
| No | 506 | 1,607 | 31.5% | Ref | Ref | ||||
| Yes | 140 | 376 | 37.2% | 1.29 | 1.02-1.63 | 0.0326 | 1.4 | 1.10-1.80 | 0.0073 |
| Household income | |||||||||
| ≤ $25,000 | 276 | 969 | 28.5% | Ref | Ref | ||||
| $25,001-$50,000 | 130 | 372 | 35.0% | 1.35 | 1.05-1.74 | 0.0213 | 1.23 | 0.94-1.61 | 0.1312 |
| > $50,000 | 149 | 315 | 47.3% | 2.25 | 1.74-2.93 | <0.0001 | 1.71 | 1.25-2.33 | 0.0007 |
| Unknown/Refused | 91 | 328 | 27.7% | 0.96 | 0.73-1.27 | 0.7973 | 0.96 | 0.72-1.29 | 0.787 |
| Enrolled subjects with AGE (index cases) | |||||||||
| Race/Ethnicity | |||||||||
| White Non-Hispanic | 169 | 375 | 45.1% | 2.24 | 1.75-2.88 | <0.0001 | 1.57 | 1.16-2.12 | 0.0032 |
| Black Non-Hispanic | 165 | 522 | 31.6% | 1.26 | 1.00-1.60 | 0.0518 | 1.17 | 0.89-1.53 | 0.256 |
| Other Non-Hispanic | 68 | 172 | 39.5% | 1.79 | 1.27-2.51 | 0.0008 | 1.49 | 1.03-2.15 | 0.0322 |
| Hispanic | 244 | 911 | 26.8% | Ref | Ref | ||||
| Unknown | 0 | 4 | 0.0% | ||||||
| Age | |||||||||
| 0-11 months | 195 | 567 | 34.4% | 1.21 | 0.91-1.61 | 0.1921 | 1.27 | 0.79-2.05 | 0.3306 |
| 1 year | 198 | 596 | 33.2% | 1.15 | 0.86-1.52 | 0.3421 | 1.18 | 0.73-1.91 | 0.4885 |
| 2-4 years | 145 | 464 | 31.3% | 1.05 | 0.78-1.41 | 0.7589 | 1.09 | 0.74-1.61 | 0.6487 |
| 5-10 years | 108 | 357 | 30.3% | Ref | Ref | ||||
| Max Vomiting Episodes in 24 hours | |||||||||
| 0-1 episode | 36 | 194 | 18.6% | Ref | Ref | ||||
| 2-4 episodes | 146 | 595 | 24.5% | 1.43 | 0.95-2.14 | 0.087 | 1.48 | 0.97-2.24 | 0.068 |
| ≥5 episodes | 464 | 1,195 | 38.8% | 2.79 | 1.90-4.07 | <0.0001 | 2.99 | 2.01-4.43 | <0.0001 |
| Diarrhea Episodes in 24 hours | |||||||||
| None | 235 | 741 | 31.7% | Ref | |||||
| ≥ 1 | 411 | 1,243 | 33.1% | 1.06 | 0.88-1.29 | 0.5344 | |||
| Duration of Symptoms ≥4 days | |||||||||
| No | 247 | 822 | 30.1% | Ref | Ref | ||||
| Yes | 399 | 1,162 | 34.3% | 1.22 | 1.00-1.48 | 0.0448 | 1.26 | 1.02-1.56 | 0.0309 |
| Child in Diaper | |||||||||
| No | 162 | 547 | 29.6% | Ref | Ref | ||||
| Yes | 484 | 1,435 | 33.7% | 1.21 | 0.98-1.50 | 0.0811 | 1.15 | 0.69-1.67 | 0.4628 |
| Child in Daycare | |||||||||
| No | 367 | 1,178 | 31.2% | Ref | Ref | ||||
| Yes | 279 | 805 | 34.7% | 1.17 | 0.97-1.42 | 0.1022 | 1.15 | 0.91-1.46 | 0.2476 |
| Modified Vesikari Score | |||||||||
| 0-10 (mild) | 409 | 1,257 | 32.5% | Ref | |||||
| 11-15 (moderate) | 208 | 640 | 32.5% | 1.00 | 0.81-1.22 | 0.9867 | |||
| ≥ 16 (severe) | 29 | 87 | 33.3% | 1.04 | 0.65-1.64 | 0.8783 | |||
| Study Site | |||||||||
| Vanderbilt | 100 | 344 | 29.1% | 1.11 | 0.81-1.54 | 0.5137 | 1.07 | 0.75-1.52 | 0.7018 |
| Rochester | 42 | 142 | 29.6% | 1.14 | 0.75-1.75 | 0.5413 | 1.00 | 0.63-1.61 | 0.9858 |
| Cincinnati | 66 | 150 | 44.0% | 2.14 | 1.44-3.17 | 0.0002 | 1.87 | 1.20-2.92 | 0.0059 |
| Seattle | 79 | 170 | 46.5% | 2.36 | 1.62-3.44 | <0.0001 | 1.86 | 1.23-2.82 | 0.0034 |
| Houston | 103 | 383 | 26.9% | Ref | Ref | ||||
| Kansas City | 145 | 453 | 32.0% | 1.28 | 0.95-1.73 | 0.107 | 1.24 | 0.89-1.73 | 0.2051 |
| Oakland | 111 | 342 | 32.5% | 1.31 | 0.95-1.80 | 0.1015 | 1.42 | 1.00-2.02 | 0.0478 |
| Surveillance Year | |||||||||
| Dec 2011 - Nov 2012 | 98 | 330 | 29.7% | 0.79 | 0.59-1.07 | 0.1346 | 0.82 | 0.59-1.14 | 0.234 |
| Dec 2012 – Nov 2013 | 143 | 397 | 36.0% | 1.06 | 0.80-1.40 | 0.6858 | 1.02 | 0.76-1.37 | 0.891 |
| Dec 2013 – Nov 2014 | 168 | 484 | 34.7% | Ref | Ref | ||||
| Dec 2014 – Nov 2015 | 133 | 460 | 28.9% | 0.77 | 0.58-1.01 | 0.0563 | 0.73 | 0.55-0.98 | 0.0358 |
| Dec 2015 – June 2016 | 104 | 313 | 33.2% | 0.94 | 0.69-1.26 | 0.6661 | 0.83 | 0.60-1.15 | 0.261 |
Discussion
HHCs of a norovirus-positive case were more likely to develop AGE symptoms than HHCs of a norovirus-negative case. The HHC (16.7%) and household (32.6%) attack rates observed in this population were within the ranges of norovirus transmission (15-33%) reported in other studies (6–10).
The greatest risk factor for transmission was ≥5 vomiting episodes in 24 hours by the index case. Vomiting is a well reported risk factor of AGE spread, due to viral shedding and significant environmental contamination by airborne droplets or fomites, and vomiting was identified as a risk factor in the MAAGE study (6, 12). Bleach-based solutions remain the best method for disinfecting hard surfaces and reducing the likelihood of norovirus transmission (5).
As seen in the MAAGE study, we found that HHCs age 0-4 years had an increased odds of developing AGE symptoms (6). While HHCs age 0-4 years had the highest attack rates, HHCs age 18-49 years made up the largest proportion (60.9%) of ill HHCs within households of norovirus-positive index cases. Among adults (18-49 years), over 90% of ill HHCs identified as the parent/guardian, demonstrating that caregivers make up a large proportion of ill HHCs. There is likely significant contact between these caregivers and the index case, due to the index case being young (<11 years) and having severe enough AGE to require care at an emergency department or hospital. While interactions between caregivers and a sick child are unavoidable, it is important to practice prevention strategies like handwashing and cleaning surfaces and laundry to reduce the possibility of transmission.
Our population is skewed towards young families since eligibility was based on a child <11 years of age seeking medical care for AGE. This limits the number of older adults among the HHCs and our ability to comment on transmission to this other at-risk population. Stool was not collected from HHCs, so transmission is based only on symptomology. We limited our dataset to HHC illness that occurred within 7 days of another AGE illness in the household to better measure household transmission, but it is possible that the illness came from another source. It is also possible that those who became sick 1 day after the index case had the same exposure as the index case. Both surveys relied on one parent or guardian providing illness information on all HHCs, which may have introduced misreporting. Recall bias may have been a factor for the follow-up interview; however, our analysis was restricted to households that completed follow-up within 7-35 days. Our surveys did not capture information on cleaning, personal hygiene, or shared bedrooms or bathrooms. This information would have been useful in understanding how different behaviors and exposure types may influence household transmission.
Most people do not seek medical care for norovirus illnesses, and follow-up studies such as this are important for understanding the burden of norovirus and its impact on households. Children <5 years of age play a large role in introducing and transmitting AGE within households, and these findings support the need for and benefits of a pediatric norovirus vaccine. A pediatric norovirus vaccine has the potential to stop the chain of transmission, resulting in reduced transmission within households and among contacts.
Supplementary Material
Acknowledgements
This work was supported by cooperative agreements with the Centers for Disease Control and Prevention (RFA-IP-11-010). We thank the children and their families who participated in this study. We thank all NVSN staff for their important contributions to the project. The New Vaccine Surveillance Network Acute Gastroenteritis Working Group includes: Claire P. Mattisona,b, Mary Moffattc, Jennifer Schusterc, Gina Weddlec, Coreen L. Johnsond,e, Robert L. Atmarf,g, Sasirekha Ramanig, James D. Chappellh, and Rendie McHenryh, Elizabeth P Schlaudeckeri,j, Chelsea Rohlfsi,j, Brittney Casselli,j, Krista Doerfleini,j, Christina Albertink,l, Wende Fregoek,l, Lynne Shelleyk,l, and Danielle Zerrm.
Potential conflicts of interest.
C.J.H. served as a co-investigator on projects in which the institution received support from GSK, Pfizer, and Merck. N.H. has received institutional grant support from Merck and served on and advisory board for CSL-Seqirus. M.A.S. has received institutional support from the National Institutes of Health, the Centers for Disease Control and Prevention, Merck, Pfizer and Cepheid for infectious disease research, is a consultant for Merck, and received royalties from UpToDate for chapters on International Adoption Medicine. G.A.W. has received institutional support from the Centers for Disease Control and Prevention and the New York State Department of Health AIDS Institute, paid consultancy from the New York State Department of Health AIDS Institute, honoraria from Merck & Co, Inhalon Biopharma, and Data Management Safety Board Honoraria from Emory University. J.A.E. has received institutional support from AstraZeneca, GSK and Pfizer and individual support from AstraZeneca, GSK, Merck, Moderna, Pfizer, Meissa Vaccines, Shionogi and Cidarra. All other authors have no reported conflicts.
aDivision of Viral Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA; bCherokee Nation Operational Solutions, Tulsa, Oklahoma, USA; cChildren’s Mercy, Kansas City, Missouri, USA; dDepartment of Pathology, Texas Children’s Hospital, Houston, Texas, USA; eDepartment of Pathology & Immunology, Baylor College of Medicine, Houston, Texas, USA; fDepartment of Medicine, Baylor College of Medicine, Houston, Texas, USA; gDepartment of Molecular Virology & Microbiology, Baylor College of Medicine, Houston, Texas, USA; hVanderbilt University Medical Center, Nashville, Tennessee, USA; iDivision of Infectious Diseases, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA; jDepartment of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA; kDepartment of Pediatrics, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA; lUR Medicine Golisano Children’s Hospital, Rochester, New York, USA; mSeattle Children’s Research Institute and the University of Washington School of Medicine, Seattle, Washington, USA.
Disclaimer.
The findings and conclusions in this report are those of the author(s) and do not necessarily represent the official position of the Centers for Disease Control and Prevention. Names of specific vendors, manufacturers, or products are included for public health and informational purposes; inclusion does not imply endorsement of the vendors, manufacturers, or products by the Centers for Disease Control and Prevention or the US Department of Health and Human Services.
Abbreviations
- AGE
acute gastroenteritis
- HHC
household contact
- OR
odds ratio
- aOR
adjusted odds ratio
- CI
confidence interval
- NVSN
New Vaccine Surveillance Network
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