title: A norovirus outbreak triggered by copper intoxication on a coach trip from the Netherlands to Germany, April 2010.
abstract: We report an unusual outbreak of norovirus infection on a coach trip. Overall, 30 of 40 people (including drivers and crew) developed nausea, vomiting and/or diarrhoea, 11 of them on the first day of the trip. The incidence epidemic curve showed a first peak on Day 1 and a second on Day 4. Nine passengers were hospitalised with gastrointestinal symptoms. Norovirus was found in stool samples from two patients, but the infection could not explain the first peak in the epidemic curve only a few hours after departure. Interviews with the passengers and an inspection of the coach and its water supply implicated the water used for coffee and tea as the potential source. Microbiological investigations of the water were negative, but chemical analysis showed a toxic concentration of copper. Blood copper levels as well as renal and liver function were determined in 28 of the 32 passengers who had been exposed to the water. One passenger who did not have gastrointestinal symptoms had an elevated copper level of 25.9 μmol/L, without loss of liver or renal function. It is likely that the spread of norovirus was enhanced because of vomiting of one of the passengers due to copper intoxication.
authors.affiliation: Department of Infectious Diseases, Public Health Service (GGD) Nijmegen, Nijmegen, the Netherlands. jhoefnagel@ggd-nijmegen.nl
authors.forename: J
authors.initials: J
authors.lastname: Hoefnagel
authors.forename: Dh
authors.initials: D
authors.lastname: van de Weerdt
authors.forename: O
authors.initials: O
authors.lastname: Schaefer
authors.forename: R
authors.initials: R
authors.lastname: Koene
mesh_terms: D017250:Caliciviridae Infections / Q000175:diagnosis / Q000453:epidemiology*; D015331:Cohort Studies; D003300:Copper / Q000009:adverse effects* / Q000097:blood*; D004196:Disease Outbreaks; D005759:Gastroenteritis / Q000175:diagnosis / Q000453:epidemiology*; D005858:Germany / Q000453:epidemiology; D006801:Humans; D018986:Motor Vehicles; D009426:Netherlands / Q000453:epidemiology; D029322:Norovirus / Q000302:isolation & purification*; D011795:Surveys and Questionnaires; D014867:Water / Q000009:adverse effects / Q000737:chemistry
chemical_list: D014867:Water; D003300:Copper