Prospective Study of Etiologic Agents of Acute Gastroenteritis Outbreaks in Child Care Centers WHITNEY H. LYMAN, DVM, JOAN F. WALSH,PHD, JONATHAN B. KOTCH, MD, DAVID J. WEBER, MD, ELIZABETH GUNN, BS, AND JAN VINJÉ,PHD Objective To investigate the etiology of outbreaks of acute gastroenteritis (AGE) in children attending childcare centers (CCCs) in North Carolina between October 2005 and March 2007. Study design In this prospective study of outbreaks of AGE in CCCs, stool specimens from symptomatic children and environmental surface swabs were tested for adenovirus group F, astrovirus, norovirus (NoV), rotavirus group A, and sapovirus using real-time and conventional reverse transcription-polymerase chain reaction assays, and viruses were genotyped by sequencing. Results A total of 29 AGE outbreaks were evaluated, of which 13 (45%) were caused by a single virus, including rotavirus group A (17%), NoV (10%), astrovirus (10%), and sapovirus (7%). Multiple viruses were detected in 3 outbreaks (10%). Environmental swabs from 13 of 22 outbreaks (59%) tested positive for at least 1 virus and confirmed the findings of the same virus in the fecal specimens for 10 of the outbreaks (45%). Conclusions This study confirms that viruses are major causes of AGE outbreak in CCCs. Our finding of widespread environmental contamination during such outbreaks suggests the need to study the effectiveness of current surface disinfec- tants against multiple gastroenteritis viruses in CCCs. (J Pediatr 2008;xx:xxx) I n developed countries, children attending child care centers (CCCs) are more likely than other children to experience episodes of gastroenteritis. 1-3 Although it has been suggested that the majority of these episodes are caused by infections with viruses such as rotavirus, norovirus (NoV), astrovirus, sapovirus and adenovirus, little data exist on these infections in young children attending CCCs. 4 Only outbreaks caused by enteric bacterial pathogens, such as Shigella spp, Campylobacter spp, and Salmonella spp, are reportable by law in most states, including North Carolina. Further- more, small clusters of gastroenteritis often are not reported, and medical treatment is based on symptomatology rather than on etiologic diagnosis. 5 In North Carolina, out of an estimated 600 768 children under age 5 years, 272 523 (44%) are cared for in regulated settings, either licensed CCCs (40.3%) or licensed family care homes (3.7%). Many other children are cared for in unlicensed group settings. Approximately 20 to 25 outbreaks of acute gastroenteritis (AGE) are reported to the North Carolina Department of Health and Human Services in a given year (J.M. Mallard, S. Jenkins, personal communication). Among the gastroenteritis viruses, group A rotaviruses are the leading cause of severe diarrheal illness in children under age 5 years, causing more than 130 million episodes and between 600 000 and 870 000 deaths per year worldwide. 6 In the United States, before universal immunization, an estimated 1 in every 73 children was hospital- ized because of diarrhea due to group A rotavirus during the first 5 years of life. 7 This virus is of particular concern in children under age 3 years who attend CCCs. 8 NoV infection is the most common cause of AGE outbreaks in people of all ages worldwide. 9 Although foodborne transmission is very common, person-to-person trans- mission is the typical mode of NoV outbreaks on cruise ships and in elementary schools, hotels, universities, CCCs, nursing homes, and hospitals. With improved molecular diagnostic methods, NoVs have been found to be as common as rotaviruses in children under age 2 years with diarrhea. 10 Sapoviruses, which belong to a separate genus of the AGE Acute gastroenteritis CCC Childcare center NoV Norovirus From the Department of Environmental Sciences and Engineering (W.L., J.V.), De- partment of Maternal and Child Health, School of Public Health (J.W., J.K., E.G.), and Division of Infectious Diseases, School of Medicine (D.W.), University of North Carolina, Chapel Hill, NC and Division of Viral Diseases, Centers for Disease Control and Prevention, Atlanta, GA (J.V.). Supported by the Thrasher Research Fund (grant 02821-5). The findings and conclu- sions in this article are those of the authors and do not necessarily represent the views of the funding agency or the Centers for Disease Control and Prevention. The au- thors declare no conflicts of interest, real or perceived. Submitted for publication Jan 30, 2008; last revision received Jun 11, 2008; accepted Jul 30, 2008. Reprint requests: Jan Vinjé, PhD, Division of Viral Diseases, Centers for Disease Control and Prevention, Mailstop G-04, Atlanta, GA 30333. E-mail: jvinje@cdc.gov. 0022-3476/$ - see front matter © 2008 Published by Mosby, Inc. 10.1016/j.jpeds.2008.07.057 1 ARTICLE IN PRESS