4 patients die due to suspected norovirus outbreak in Kyoto hospital

The infection route is not properly washing hands. Exactly where remains a question but not washing properly is the cause.

... how do you die of gastroenteritis in this day and age? One cannot die directly from the norovirus, rather one dies from dehydration as a result of vomiting and diarrhea. The dehydration can be treated with anti-emetics (to stop vomiting), suppository medications (to stop diarrhea), and an IV (to replace lost fluids). To allow vomiting and diarrhea to continue to such an extent that someone actually dies from them in a first-world hospital requires an explanation... it simply should not have happened under normal circumstances.

sillygirlJan. 23, 2014 - 07:33AM JST

The infection route is not properly washing hands. Exactly where remains a question but not washing properly is the cause.

Actually this is not entirely true. When someone vomits in a group ward a small degree of the vomit is in the form of a fine spray, which can easily travel to the people in the surrounding beds, which is why it is standard procedure to move anyone suffering from gastroenteritis to a private room or into a quarantine ward. While most modern hospitals should have special anti-viral and anti-bacterial filters on their air-conditioning my experience has been that these are often either incorrectly installed (i.e. installed only between floors, not between rooms), or badly maintained (I recall one hospital where they hadn't been maintained in 5 years, resulting in them becoming major health hazards), or simply not installed at all (which is the case in many older hospitals). The air-conditioning can result in the fine vomit spray being speedily and efficiently transferred from one room to another.

It may also have been sprayed onto the medical staff's clothing. Almost all medical staff will remember to change gloves between patients, but may neglect to change gowns (or more gowns may simply be unavailable), and so the nurse helping you to sit up may accidentally be bringing you into contact with the virus.

Norovirus is not, strictly speaking, airborne, but it can behave in many ways like an airborne virus because of the misting effect when people vomit. This is not normally an issue in most people's lives as at home people tend to go into a closed room to vomit (the toilet), however in hospitals the situation is different.

"how do you die of gastroenteritis in this day and age?"

I went through this last year and it was really a horrible experience. You can treat it to a certain extent but given the violent physical toll on your body I can see how the elderly are at risk.

The elder's body can no longer take what the younger's body could esdpecially when there is someone in the hospital not taking the correct procedures when confronting a virus.

WASH YOUR HANDS OR SUFFER FROM NOT DOING IT.

I'm guessing those who died were already in a pretty awful condition even before they contracted the virus. The nursing care here falls far short of western standards.

I consider myself normally to be in pretty good condition health-wise, but a bout of noro really knocked me for six. I can well understand infants and the elderly not being able to cope.

The dehydration can be treated with anti-emetics (to stop vomiting), suppository medications (to stop diarrhea), and an IV (to replace lost fluids).

They're better than nothing, granted, but in severe cases they can have little effect. The noro just flushes it all out again.

And yes, washing your hands is Hygiene 101, but noro can still get to you.

Sorry, I should expand; I mean medical nursing care as opposed to just peripheral stuff such as changing the bed sheets, sweeping the floor, helping people lift up their shirt etc....all of the latter are carried out extremely diligently here.

I've heard the virus's infectivity is strong, difficult to prevent. Very scary.

cleoJan. 23, 2014 - 08:57AM JST

The dehydration can be treated with anti-emetics (to stop vomiting), suppository medications (to stop diarrhea), and an IV (to replace lost fluids).

They're better than nothing, granted, but in severe cases they can have little effect. The noro just flushes it all out again.

There are two errors in your statement:

I'm not talking about over-the-counter low-dose immodium here. Hospitals would give an IV antiemetic like ondansetron. This would be effective in 99% of cases. Yes, some vomiting and diarrhea might continue in that 1% of cases, but the goal is to slow them down. An IV of something like bolus isotonic would replace fluids faster than they were being lost. This would prevent death.

These deaths should have been preventable.

... how do you die of gastroenteritis in this day and age? One cannot die directly from the norovirus, rather one dies from dehydration as a result of vomiting and diarrhea. The dehydration can be treated with anti-emetics (to stop vomiting), suppository medications (to stop diarrhea), and an IV (to replace lost fluids). To allow vomiting and diarrhea to continue to such an extent that someone actually dies from them in a first-world hospital requires an explanation... it simply should not have happened under normal circumstances.

Because this is Japan, and when a patient complains about a problem, it must go all the way up the chain of command before a simple treatment can be authorized. The nationalzed healthcare system requires that every moment of treatment and all drugs administered be carefully documented, and each and every one must be approved. If the doctor is gone for the day, the authorization and treatment will have to wait until he returns. As usual, bureaucracy must be satisfied before any action is taken.

I worked in an Army hospital years ago, and norovirus outbreaks occasionally occurred, but no one ever died from it, despite the fact that most of the patients were old WW2 vets. Even I, a simple medic, was empowered to initiate emergency treatment if a doctor or RN wasn't available. Here in Japan, nothing can be done without permission and the requisite paperwork.

sangetsu03Jan. 23, 2014 - 09:32AM JST

I worked in an Army hospital years ago, and norovirus outbreaks occasionally occurred, but no one ever died from it...

The article doesn't say anyone died from noro. I believe it's fairly common for the elderly to die of pneumonia though.

@ Frungi your idea is not new, as is the standard treatment for a norovirus Infection. Despite of that, still some people die. What most people don't know, the virus can survive in the water for many days and is resistant to normal soap that we use at home.

The virus can survive on surfaces for quite a long time. And I believe soap and alcohol will not kill it. Only bleach is effective.

Frungy, in severe cases you wouldn't be dealing with over-the-counter medication. These were people already in hospital, so presumably their systems were already weakened by whatever it was they were hospitalised for, plus the people who died were all of advanced age. If all medication worked as it was supposed to do all the time, the average lifespan would be double what it is. We're all going to die of something eventually, and already ill enough to be in hospital, aged around 80-90, with the extra whammy of noro, sounds a lot like eventually to me. Presumably the 101-plus people who got noro and didn't die weren't so old and sick to start off with that their bodies were able to take advantage of the treatment they were given.

The big question is how so many people were able to become infected in a supposedly clean environment like a hospital (yes I know, hospitals aren't really all that clean, teeming with germs - but they shouldn't be teeming with noro) and for the infection to spread to so many before it was detected. When noro hits, it really isn't something you don't notice. The incubation period is up to a couple of days, so 9 days before they twigged seems a long time. Were they just watching all the people exploding from both ends and muttering Oh what a coincidence?

Probably best to start looking in the hospital kitchens for the source. Some low-paid dishwasher who couldn't afford to take a couple of days off?.

Hmm, handwashing and noro virus preventin go hand in hand. As for people washing their hands, its virtually non-existent among elderly men in train station restrooms,(neither is hand soap readily available) and the younger generation, again men in particular, dont seem much better.

and is resistant to normal soap that we use at home.

Most agenices recommend using soap and water and then hand sanitizer if available. The soap will not kill the virus, but both it and lots of water can help remove it from your hands. One key is to thoroughly wash with soap and copious amounts of water. Neither the water nor the soap kill the virus, but the idea is to use enough water to wash it off the skin.

Some people use hand sanitizer in place of hand washing. This should only be done in cases where it is not possible to wash one's hands.

As for people washing their hands, its virtually non-existent among elderly men in train station restrooms,(neither is hand soap readily available) and the younger generation, again men in particular, dont seem much better.

I agree. I have seen many men not washing their hands after using the restroom. I cannot imagine not washing after using the toilet, but it is much more common than many realize.

Ghost riderJan. 23, 2014 - 12:45PM JST @ Frungi your idea is not new, as is the standard treatment for a norovirus Infection. Despite of that, still some people die. What most people don't know, the virus can survive in the water for many days and is resistant to normal soap that we use at home.

This isn't my "idea", this is the treatment I normally use... except in Japan where it IS a new idea and where I have encountered strong resistance when I suggested this course of action.

cleoJan. 23, 2014 - 01:04PM JST Frungy, in severe cases you wouldn't be dealing with over-the-counter medication. These were people already in hospital,

If you had actually done me the courtesy of reading my post you would realise that this was precisely the point I was making. And hospital grade medications are effective 99% of the time... and if they're not effective then one has several others to choose from. This is precisely WHY people are living much longer. People dying from old age I have no problem with, but even elderly patients dying from dehydration is just unacceptable.

One of the main ways norovirus is transmitted is when the virus is aerosolised by the toilet flushing after someone with noro has used it- you can wash your hands all you like, and you won't avoid catching it that way.

As for the people who blame the nursing staff for the elderly people being in a bad way- they were in a HOSPITAL, therefore they were most likely not in the best of health to begin with. My otherwise healthy grandmother caught it when it went through our family one Christmas (yes, we were very diligent about handwashing, but we got it anyway!) and it was just about the end of her even though she wasn't in a hospital.

Hand sanitiser and other alcohol-based disinfectants don't kill noro by the way, you need to hit it with bleach to actually kill it.

If you had actually done me the courtesy of reading my post....

Ooops, Frungy's got the grumpies.... :-)

you would realise that this was precisely the point I was making. ....even elderly patients dying from dehydration is just unacceptable.

And if you'd done me the courtesy etc., (I'm not grumpy, just ribbing you) you'd realise that my point was that these were people who were already sick and very old. The article says the cause of death was pneumonia (a common cause of death in the elderly when they're already weakened by something else) or gastroenteritis - (aka noro) again, if you're already weakened by some illness and old age, not all that surprising. And, according to the article linked below, the use of antibiotics (not unlikely in people who are hospitalised) makes the intestines more vulnerable to infection.

Have you ever had noro? It can be pretty extreme.

http://www.nytimes.com/2012/03/20/health/gut-infections-are-growing-much-more-lethal.html?pagewanted=all&_r=0

cleoJan. 23, 2014 - 03:39PM JST Ooops, Frungy's got the grumpies.... :-)

And if you'd done me the courtesy etc., (I'm not grumpy, just ribbing you) you'd realise that my point was that these were people who were already sick and very old. The article says the cause of death was pneumonia (a common cause of death in the elderly when they're already weakened by something else) or gastroenteritis - (aka noro) again, if you're already weakened by some illness and old age, not all that surprising. And, according to the article linked below, the use of antibiotics (not unlikely in people who are hospitalised) makes the intestines more vulnerable to infection.

And my point was that one does not die of noro. One actually dies of dehydration, which is really ridiculously simple to stop even in the most elderly patients if one has access to a modern hospital's supplies. For patients to die of dehydration means that someone messed up...badly.

I'm sorry that people dying for no reason makes me grumpy. Clearly this is a personal failing of mine and I should be a happy little sociopath like some other people.

Isn't radiation the best way to kill the norovirus? And washing hands is not a foolproof way of preventing infection.

I'm a working woman, in the course of an average working day I use perhaps three or four different public facilities, in stations, department stores, and other places. It is simply unavoidable for me.

I would deeply appreciate the following:

Hot water.

Paper towels (the cold hand dryers just don't cut it).

Toilet seat lids! Yes, you read that right. Toilet seat lids.

I think if we had these three things, plus a little public education about not coughing and sneezing in people's faces, then the spread of all these nasty contagious diseases would be dramatically lessened in even a year or so.

All those in favor say aye!

Copper destroys the norovirus.

Scientists from the University of Southampton have discovered that copper and copper alloys rapidly destroy norovirus - the highly-infectious sickness bug.

The study, which was designed to simulate fingertip-touch contamination of surfaces, showed norovirus was rapidly destroyed on copper and its alloys, with those containing more than 60 per cent copper proving particularly effective.

I'm sorry that people dying for no reason makes me grumpy.

To my knowledge, none of the posters posting here had anything to do with these deaths.

There's scope for a "toilet chain" luxury warm clean toilets which are manned with everything you need including shoe cleaning, taking a quick shower, brushing down your clothes. Breast feeding area. Basic membership plus a use fee?

This is a great idea, and I think it'll catch on soon, considering the amount of power wielded by hygiene-obsessed Japanese women with large disposable incomes. Have you ever used the lavs in Zurich Station? Spotlessly clean, with shower facilities and toilets that are cleaned between every single use. There is a small fee, but it's worth it.

I think if we had these three things, plus a little public education about not coughing and sneezing in people's faces, then the spread of all these nasty contagious diseases would be dramatically lessened in even a year or so.

I couldn`t agree more. That, and for people to be taught to NOT pick their noses and then grab the handrail, and to wash their hands after their ablutions. Instead of an automatic cold tap, hot water should also be available in public restrooms - and naturally handsoap. All of the above would help

Copper destroys the norovirus. Scientists from the University of Southampton have discovered that copper and copper alloys rapidly destroy norovirus - the highly-infectious sickness bug. The study, which was designed to simulate fingertip-touch contamination of surfaces, showed norovirus was rapidly destroyed on copper and its alloys, with those containing more than 60 per cent copper proving particularly effective.

It's true: http://www.medicalnewstoday.com/articles/265803.php

You do all realise that the copper thing is old news? They've been using copper pots in India to kill cholera and other infectious diseases for literally thousands of years.

FrungyJan. 23, 2014 - 05:20PM JST

And my point was that one does not die of noro. One actually dies of dehydration, which is really ridiculously simple to stop....

Frungy, why are you fixated on dehydration? Isn't it possible that the emergency treatments for gastroenteritis weren't enough when combined with the countless other possible illnesses that these already hospitalized elderly people had? BTW, here's something from a report from the Center for Disease Control and Prevention website regarding "Acute Gastroenteritis" (AGE) in the U.S.:

...During 2009-2010, a total of 2,259 person-to-person AGE outbreaks were reported in NORS from 42 states and the District of Columbia. These outbreaks resulted in 81,491 reported illnesses, 1,339 hospitalizations, and 136 deaths. No etiology was reported in approximately 40% (n = 840) of outbreaks. Of the remaining 1,419 outbreaks with a reported etiology, 1,270 (89%) were either suspected or confirmed to be caused solely by norovirus....

...The elderly also accounted for 83% of AGE-associated deaths, of which norovirus was the second leading infectious cause after Clostridium difficile (26). A literature review of norovirus outbreaks during 1993-2011 indicated that hospitalizations and deaths were significantly more likely when outbreaks occurred in health-care settings, including LTCFs (27). The findings in this report affirm that norovirus can account for substantial morbidity and mortality among persons with acute gastrointestinal illness in the United States, particularly among the elderly....

Link: http://www.cdc.gov/mmwr/preview/mmwrhtml/ss6109a1.htm

"sillygirlJAN. 23, 2014 - 07:33AM JST The infection route is not properly washing hands. Exactly where remains a question but not washing properly is the cause."

You are not a silly girl. Having spent time in a number of hospitals in Japan, I've watched all staff, nurses/doctors go from patient to patient, room to room, with no masks, and unwashed hands. Washing hands is the first step in health care.

TahoochiJan. 24, 2014 - 02:46AM JST

And my point was that one does not die of noro. One actually dies of dehydration, which is really ridiculously simple to stop....

Frungy, why are you fixated on dehydration? Isn't it possible that the emergency treatments for gastroenteritis weren't enough when combined with the countless other possible illnesses that these already hospitalized elderly people had?

Tahoochi, I really don't know how to explain it more simply than I have above. I'll try. The gastroenteritis (or noro as it is called in Japan) is either a bacterial or viral infection that causes vomiting and diarrhea. Vomiting and diarrhea aren't normally inherently dangerous, what is dangerous is one cannot replace the lost liquids... at which point one dies from dehydration. Therefore what these people died from wasn't gastroenteritis/noro, but rather from dehydration (or hypernatraemia).

I note your quote from the CDC. The CDC statistics deal with the whole country. This includes solitary old people who's partner has died, who can't drive, and who may be of the generation that believe in "toughing it out", or may have been reluctant to go to hospital because of the cost.

The difference in this case is that these elderly people were in a hospital, supervised by medical personnel who should all be able to recognise the signs of acute dehydration, and who had access to the medications required to replace the lost fluids quickly and easily. It would have been as simple as putting up an IV, and if the rate of fluid loss was higher than the rate of fluid intake then further steps (such as anti-emetics) could have been used.

So stating that mostly elderly people die of gastro is true, but no-one should die of gastro in a first world hospital if the staff are doing their jobs properly.

Do you know what the mortality rate is for norawalk viruses is in U.S. hospitals? 0%. (Source: Food-Related Illness and Death in the United States, Mead et. al., 1999). Other food-related illnessess? All less than 0.5%, and normally a LOT less than 0.5%. The mortality rate in the article above? 3.8%.

Something is wrong. I understand that for laypeople you may be unfamiliar with the standard mortality rates for diseases, and that I drew a distinction between norovirus (cause of the vomiting/diarrhea) and dehydration(cause of death), but a lot of things about this article point to a dysfunctional health care system in Japan. They don't even know if the patients died of noro-induced dehydration or if they died of influenza. That's just crazy, because that is something you should be able to tell with only a brief examination of the corpse (it doesn't require a full autopsy because the causes of death are so totally different).

RecklessJan. 24, 2014 - 05:07PM JST @Frungy, although I totally agree with you, I am not sure Japan is that bad. On a visit to NYC last year and visiting a public toilet, the sink was ripped out of the wall, there was shytt on everything, the toiled seat was cracked let alone covered, the toilet paper was so thin that whatever you wiped got onto whatever you were wiping with and talk about soap??? forgetaboutit,,,

I can see your point about public toilets, however my point was that the staff in the hospitals are badly trained. The equipment is there, the medication is there... all that's lacking is the knowledge of how and when to use it appropriately.

however my point was that the staff in the hospitals are badly trained. The equipment is there, the medication is there... all that's lacking is the knowledge of how and when to use it appropriately.

You have brought nothing to the table to show that these particular deaths were the fault of human error. It is just your assumption. It is understandable, however. Often laypeople, such as yourself, are not aware of the fact that deaths occur even when medical professionals do everything correctly.