Quantifying the relative effects of environmental and direct transmission of norovirus

Background: Norovirus is a common cause of outbreaks of acute gastroenteritis in health- and child-care settings, with serial outbreaks also frequently observed aboard cruise ships. The relative contributions of environmental and direct person-to-person transmission of norovirus has hitherto not been quantified. Objective: We employ a novel mathematical model of norovirus transmission, and fit the model to daily incidence data from a major norovirus outbreak on a cruise ship, and examine the relative efficacy of potential control strategies aimed at reducing environmental and/or direct transmission. Results: The reproduction number for environmental and direct transmission combined is Rtot = 11.0 [9.4,15.6], and of environmental transmission alone is Renviron = 0.85 [0.18,2.04]. Direct transmission is overwhelmingly due to 0 passenger-to-passenger contacts, but crew can act as a reservoir of infection from cruise-to-cruise. Implications: This is the first quantification of the relative roles of environmental and direct transmission of norovirus. While environmental transmission has the potential to maintain a sustained series of outbreaks aboard a cruise ship in the absence of strict sanitation practices, direct transmission dominates. Quarantine of ill passengers and cleaning are likely to have little impact on final outbreak size, but intensive promotion of good hand washing practices can prevent outbreaks.