Search

Objectives: The Menstrual Practice Needs Scale (MPNS) is a comprehensive measure of menstrual self-care experience including access to sufficient, comfortable materials to catch or absorb bleeding, supportive spaces for managing menstruation and for disposal and laundering of used materials. It addresses a critical measurement gap to improve quantitative menstrual health research and programme evaluation. The scale was validated in a population of adolescent schoolgirls. This study appraises its performance among adult women., Design: Cross-sectional survey., Setting and Participants: Seven cognitive interviews provided insights into the interpretability of scale items. A survey of 525 working women who had menstruated in the past 6 months (435 working in markets, 45 in schools and 45 working in healthcare facilities) in Mukono District, Uganda was used to test the dimensionality, reliability and validity of the measure., Results: The 36 scale items were well understood by the study population. Dimensionality was tested for the 28 items relevant to women disposing of menstrual materials and 32 items relevant to those washing and reusing materials. The original subscale structure fit with the data, however, fell short of recommended thresholds for those disposing of materials (root mean squared error of approximation, RMSEA=0.069; Comparative Fit Index, CFI=0.840; Trucker-Lewis Index, TLI=0.824). An alternative subscale structure was an acceptable fit for those disposing (RMSEA=0.051; CFI=0.911; TLI=0.897) and reusing materials (RMSEA=0.053; CFI=0.915; TLI=0.904). MPNS total and subscale scores demonstrated acceptable internal consistency. Higher scores reflected more positive menstrual experiences and were associated with well-being (total score r=0.24, p<0.001), not missing work due to the last menstrual period (total score OR=2.47 95% CI 1.42 to 4.30) and confidence to manage menstruation., Conclusions: The MPNS offers a valid and reliable way to assess menstrual health needs. The revised factor structure can be used for samples of adult workers. Findings also highlight challenges in assessing the variety of experiences relevant to managing menstrual bleeding., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

As initiatives to support menstrual health are implemented globally, monitoring progress through a set of comprehensive indicators provides important feedback to direct policies and programs. One proposed core indicator is awareness of menstruation at menarche. That is, at the time of menarche an adolescent girl knowing that menstrual bleeding is something she will experience. In this investigation, we undertook secondary analysis of data collected across four studies to support interpretation of this indicator. We (1) describe the proportion of each sample aware of menstruation at menarche, (2) test variations in awareness according to sociodemographic characteristics, and (3) describe the associations between this indicator and self-reported experience at menarche, social support, and confidence to manage menstruation. Studies included cross-sectional survey data from 421 schoolgirls in Magway, Myanmar, 537 schoolgirls in Soroti, Uganda, 1,359 schoolgirls in Netrokona, Bangladesh, and 599 adult women working in Mukono, Uganda. Awareness of menstruation at menarche varied from 84% in Myanmar to 34% in Bangladesh. Older age at menarche was associated with awareness. Awareness at menarche was not associated with household poverty in the adolescent samples, but greater poverty was associated with lower levels of awareness among adult women. In Myanmar, girls aware of menstruation had significantly higher odds of reporting that they felt prepared (2.85 95% CI 1.34-6.08), happy (OR = 3.81 95% CI 1.74-8.37) and knew what was happening at menarche (OR = 2.37 95% CI 1.34-4.19). However, they also reported higher levels of embarrassment (OR = 1.76 95% CI 1.04-2.97) and did not report significantly less fear (OR = 1.24 95% CI 0.82-1.85). Awareness of menstruation at menarche was associated with higher scores on a menstrual knowledge quiz in both Myanmar (b = 9.51 95% CI 3.99-15.04) and Bangladesh (b = 4.78 95% CI 1.70-7.87). In these studies girls aware of menstruation at menarche also had higher odds of reporting they felt confident discussing menstruation with support sources and managing menstruation at school, while these differences were not significant among schoolgirls in Uganda. Findings support the usefulness of awareness of menstruation at menarche as an indicator to describe minimal knowledge of menstruation and suggest that awareness may signal greater knowledge, social support, and confidence in some settings., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Hennegan, Swe, Than, Smith, Sol, Alberda, Bukenya, Kibira, Makumbi, Schwab and Azzopardi.)

Human noroviruses (HuNoV) are the leading cause of gastrointestinal illness and environmental monitoring is crucial to prevent HuNoV outbreaks. The recent development of a HuNoV cell culture assay in human intestinal enteroids (HIEs) has enabled detection of infectious HuNoV. However, this complex approach requires adaptation of HIEs to facilitate HuNoV replication from environmental matrixes. Integrating data from 200 experiments, we examined six variables: HIE age, HIE basement membrane compounds (BMC), HuNoV inoculum processing, HuNoV inoculum volume, treatment of data below limit of detection (LOD), and cutoff criteria for determining positive HuNoV growth. We infected HIEs with HuNoV GII.4 Sydney positive stool and determined 1.4 × 10 3 genome equivalents per HIE well were required for HuNoV replication. HIE age had minimal effect on assay outcomes. LOD replacement and cutoff affected data interpretation, with lower values resulting in higher estimated HuNoV detection. Higher inoculum volumes lead to minimal decreases in HuNoV growth, with an optimal volume of 250uL facilitating capture of low concentrations of HuNoVs present in environmental isolates. Processing of HuNoV inoculum is valuable for disinfection studies and concentrating samples but is not necessary for all HIE applications. This work enhances the HuNoV HIE cell culture approach for environmental monitoring. Future HIE research should report cell age as days of growth and should clearly describe BMC choice, LOD handling, and positive cutoff., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Reports of school and work absences due to unmet menstrual needs have prompted increased attention to menstruation in policy and practice. However, there appear to be few quantitative studies reported in published literature capturing the prevalence of this hypothesised absenteeism. This study undertook secondary analysis of nationally representative Performance Monitoring and Accountability 2020 (PMA2020) data from Burkina Faso and Nigeria, and city-representative data from Niamey, Niger to determine the extent of women's and girls' self-reported absence from school and work due to menstruation. Among women and adolescent girls aged 15-49 years who had worked outside the household in the past month in Burkina Faso ( n  = 998), Niger ( n  = 212) and Nigeria ( n  = 3638), 19%, 11% and 17%, respectively, reported missing work due to menstruation. Among those aged 15-24 years who attended school in the past year in Burkina Faso ( n  = 461), Niger ( n  = 213) and Nigeria ( n  = 1574), 17%, 15% and 23% reported missing school in the past year due to menstruation. Findings support the assertion that menstruation is a source of absenteeism in West Africa and indicate that greater attention from research, practice, and policy is needed. In presenting this data we also reflect critically on the performance of questions regarding menstrual-related absenteeism in national monitoring surveys. Future monitoring efforts should consider the interpretability of similar survey data when many respondents did not attend any school or work and were ineligible to answer questions regarding absenteeism. Further, without additional research identifying the reasons for absenteeism, findings from similar survey questions may be difficult to interpret with relevance for policy decision making.

Background: Attention to women's and girls' menstrual needs is critical for global health and gender equality. The importance of this neglected experience has been elucidated by a growing body of qualitative research, which we systematically reviewed and synthesised., Methods and Findings: We undertook systematic searching to identify qualitative studies of women's and girls' experiences of menstruation in low- and middle-income countries (LMICs). Of 6,892 citations screened, 76 studies reported in 87 citations were included. Studies captured the experiences of over 6,000 participants from 35 countries. This included 45 studies from sub-Saharan Africa (with the greatest number of studies from Kenya [n = 7], Uganda [n = 6], and Ethiopia [n = 5]), 21 from South Asia (including India [n = 12] and Nepal [n = 5]), 8 from East Asia and the Pacific, 5 from Latin America and the Caribbean, 5 from the Middle East and North Africa, and 1 study from Europe and Central Asia. Through synthesis, we identified overarching themes and their relationships to develop a directional model of menstrual experience. This model maps distal and proximal antecedents of menstrual experience through to the impacts of this experience on health and well-being. The sociocultural context, including menstrual stigma and gender norms, influenced experiences by limiting knowledge about menstruation, limiting social support, and shaping internalised and externally enforced behavioural expectations. Resource limitations underlay inadequate physical infrastructure to support menstruation, as well as an economic environment restricting access to affordable menstrual materials. Menstrual experience included multiple themes: menstrual practices, perceptions of practices and environments, confidence, shame and distress, and containment of bleeding and odour. These components of experience were interlinked and contributed to negative impacts on women's and girls' lives. Impacts included harms to physical and psychological health as well as education and social engagement. Our review is limited by the available studies. Study quality was varied, with 18 studies rated as high, 35 medium, and 23 low trustworthiness. Sampling and analysis tended to be untrustworthy in lower-quality studies. Studies focused on the experiences of adolescent girls were most strongly represented, and we achieved early saturation for this group. Reflecting the focus of menstrual health research globally, there was an absence of studies focused on adult women and those from certain geographical areas., Conclusions: Through synthesis of extant qualitative studies of menstrual experience, we highlight consistent challenges and developed an integrated model of menstrual experience. This model hypothesises directional pathways that could be tested by future studies and may serve as a framework for program and policy development by highlighting critical antecedents and pathways through which interventions could improve women's and girls' health and well-being., Review Protocol Registration: The review protocol registration is PROSPERO: CRD42018089581., Competing Interests: The authors have declared that no competing interests exist.

Background: Norovirus is a leading cause of acute gastroenteritis worldwide. Routine norovirus diagnosis requires stool collection. The goal of this study was to develop and validate a noninvasive method to diagnose norovirus to complement stool diagnostics and to facilitate studies on transmission., Methods: A multiplex immunoassay to measure salivary immunoglobulin G (IgG) responses to 5 common norovirus genotypes (GI.1, GII.2, GII.4, GII.6, and GII.17) was developed. The assay was validated using acute and convalescent saliva samples collected from Peruvian children <5 years of age with polymerase chain reaction (PCR)-diagnosed norovirus infections (n = 175) and controls (n = 32). The assay sensitivity and specificity were calculated to determine infection status based on fold rise of salivary norovirus genotype-specific IgG using norovirus genotype from stool as reference., Results: The salivary assay detected recent norovirus infections and correctly assigned the infecting genotype. Sensitivity was 71% and specificity was 96% across the evaluated genotypes compared to PCR-diagnosed norovirus infection., Conclusions: This saliva-based assay will be a useful tool to monitor norovirus transmission in high-risk settings such as daycare centers or hospitals. Cross-reactivity is limited between the tested genotypes, which represent the most commonly circulating genotypes., (© The Author(s) 2018. Published by Oxford University Press for the Infectious Diseases Society of America.)

With increasing interest in peracetic acid (PAA) as a disinfectant in water treatment processes, this study determined PAA treatment effects on human noroviruses (hNoVs) genotype I (GI) and genotype II (GII) as well as effects on bacteriophage MS2 and murine norovirus (MNV) in relation to pH. Across all pH conditions, PAA achieved between 0.2 and 2.5 log 10 reduction of hNoVs over 120 min contact time in buffer solution as measured by reverse transcription-qPCR (RT-qPCR). The PAA treatments produced similar RT-qPCR reductions of MS2 and MNV, in the range of 0.2-2.7 log 10 . Infectivity assays achieved > 4 log 10 reduction of both MS2 and MNV in buffer solution after 120 min contact time. Comparing PAA activity across varying pH, disinfection at pH 8.5, in general, resulted in less reduction of infectivity and molecular signals compared to pH conditions of 6.5 and 7.5. This difference was most pronounced for reductions in infectivity of MNV and MS2, with as much as 2.7 log 10 less reduction at pH 8.5 relative to lower pH conditions. This study revealed that PAA was an effective disinfectant for treatment of hNoV GI and GII, MS2 and MNV, with greatest virus reduction observed for MS2 and MNV infectivity. RT-qPCR reductions of MS2 and MNV were lower than concurrent MS2 and MNV infectivity reductions, suggesting that observed hNoV RT-qPCR reductions may underestimate reductions in hNoV infectivity achieved by PAA. Although virus disinfection by PAA occurred at all evaluated pH levels, PAA is most effective at pH 6.5-7.5.

Peracetic acid (PAA) is a strong oxidant/bactericide that has been applied in various industries (e.g., food processing, pharmaceuticals, medical device sterilization, etc.) as a disinfectant. There is increasing interest in using PAA for wastewater disinfection because it does not form halogenated byproducts, and no post-treatment quenching is required. Previous studies have demonstrated good efficiency in controlling bacteria in wastewater, but limited information is available for viruses, especially those hosted by mammals (e.g., norovirus). Therefore, a study on the infectivity reduction of murine norovirus (MNV) was undertaken to evaluate the disinfection efficacy of PAA or UV alone and in combination with UV irradiation in undisinfected secondary effluent from a municipal wastewater reclamation facility (MWW) and phosphate buffer solution (PBS) at pH 7. Experiments employing MS2 bacteriophage were also performed in parallel for comparison purposes. MS2 infectivity reduction was found to be lower than MNV infectivity reduction for each condition studied - PAA, PAA + UV, and UV disinfection. These data suggest that MS2 may not be an appropriate surrogate to accurately predict the reduction of MNV infectivity. UV irradiation, in a dose range of 5-250 mJ/cm 2 , provided linear log inactivation (-log (N/N 0 )) with a regression slope (cm 2 mJ -1 ) of 0.031-0.034 and 0.165-0.202 for MS2 and MNV, respectively. UV irradiation provided similar inactivation for MS2 and MNV in both suspensions (PBS or MWW). Low infectivity reduction of MS2 was observed when PAA was used alone at a practical dose of 1.5 mg/L and below. A greater reduction of both MNV and MS2 was observed in PAA disinfection experiments using PBS as the microbial suspension medium, than in secondary effluent. Similar results were observed in PAA + UV experiments, in which greater synergistic effects were found in PBS than in MWW. Results of OH radical formation experiments suggest the presence of radical scavengers in MWW, which resulted in less opportunity for MNV and MS2 to encounter OHradicals. This study also demonstrated that the type of water can have a substantial impact on wastewater disinfection when employing PAA or PAA + UV treatment due to the matrix effect and the presence of radical scavengers, respectively. The results from this study could be employed to aid in the conceptual design of PAA and UV disinfection facilities, especially when norovirus is the organism of concern., (Copyright © 2018. Published by Elsevier Ltd.)

One key assumption impacting data quality in viral inactivation studies is that reduction estimates are not altered by the virus seeding process. However, seeding viruses often involves the inadvertent addition of co-constituents such as cell culture components or additives used during preparation steps which can impact viral reduction estimates by inducing non-representative oxidant demand in disinfection studies and fouling in membrane assessments. The objective of this study was therefore to characterize a mammalian norovirus surrogate, murine norovirus (MNV), and bacteriophage MS2 at sequential stages of viral purification and to quantify their potential contribution to artificial oxidant demand and non-representative membrane fouling. Our results demonstrate that seeding solvent extracted and 0.1 micron filtered MNV to ~10 5 PFU/mL in an experimental water matrix will result in additional total organic carbon (TOC) and 30 min chlorine demand of 39.2 mg/L and 53.5 mg/L as Cl 2 , respectively. Performing sucrose cushion purification on the MNV stock prior to seeding reduces the impacts of TOC and chlorine demand to 1.6 and 0.15 mg/L as Cl 2 , respectively. The findings for MNV are likely relevant for other mammalian viruses propagated in serum-based media. Thus, advanced purification of mammalian virus stocks by sucrose cushion purification (or equivalent density-based separation approach) is warranted prior to seeding in water treatment assessments. Studies employing bacteriophage MS2 as a surrogate virus may not need virus purification, since seeding MS2 at a concentration of ~10 6 PFU/mL will introduce only ~1 mg/L of TOC and ~1 mg/L as Cl 2 of chlorine demand to experimental water matrices.

Purpose of Review: This review discusses the utility of pathogen-specific antibody biomarkers for improving estimates of the population burden of waterborne infections, assessing the fraction of infections that can be prevented by specific water treatments, and understanding transmission routes and the natural history and ecology of disease in different populations (including asymptomatic infection rates)., Recent Findings: We review recent literature on the application of pathogen-specific antibody response data to estimate incidence and prevalence of acute infections and their utility to assess the contributions of waterborne transmission pathways. Advantages and technical challenges associated with the use of serum versus minimally invasive salivary antibody biomarkers in cross-sectional and prospective surveys are discussed. We highlight recent advances and challenges and outline future directions for research, development, and application of antibody-based and other immunological biomarkers of waterborne infections.

Norovirus infections are one of the most prominent public health problems of microbial origin in the U.S. and other industrialized countries. Surveillance is necessary to prevent secondary infection, confirm successful cleanup after outbreaks, and track the causative agent. Quantitative mass spectrometry, based on absolute quantitation with stable-isotope labeled peptides, is a promising tool for norovirus monitoring because of its speed, sensitivity, and robustness in the face of environmental inhibitors. In the current study, we present two new methods for the detection of the norovirus genogroup I capsid protein using electrospray and matrix-assisted laser desorption/ionization (MALDI) mass spectrometry. The peptide TLDPIEVPLEDVR was used to quantify norovirus-like particles down to 500 attomoles with electrospray and 100 attomoles with MALDI. With MALDI, we also demonstrate a detection limit of 1 femtomole and a quantitative dynamic range of 5 orders of magnitude in the presence of an environmental matrix effect. Due to the rapid processing time and applicability to a wide range of environmental sample types (bacterial lysate, produce, milk, soil, and groundwater), mass spectrometry-based absolute quantitation has a strong potential for use in public health and environmental sciences., (Copyright © 2014 Elsevier B.V. All rights reserved.)

Surface disinfection, as part of environmental hygiene practices, is an efficient barrier to gastroenteritis transmission. However, surface disinfectants may be difficult to obtain in remote, resource-limited, or disaster relief settings. Electrochemical oxidants (ECO) are chlorine-based disinfectants that can be generated using battery power to electrolyze brine (NaCl) solutions. Electrolysis generates a mixed-oxidant solution that contains both chlorine (HOCl, OCl(-)) and reactive oxygen species (e.g., ·OH, O3, H2O2, and ·O2-) capable of inactivating pathogens. One onsite generator of ECO is the Smart Electrochlorinator 200 (SE-200, Cascade Designs, Inc.). In a laboratory study, we assessed ECO surface disinfection efficacy for two gastrointestinal virus surrogates: bacteriophage MS2 and murine norovirus MNV-1. We quantified both infectivity and nucleic acid inactivation using culture-dependent and independent assays. At free available chlorine concentrations of 2,500 ppm and a contact time of 30 s, ECO inactivation of infective MS2 bacteriophage exceeded 7 log10 compared to MNV-1 disinfection of approximately 2 log10. Genomic RNA inactivation was less than infective virus inactivation: MS2 RNA inactivation was approximately 5 log10 compared to MNV-1 RNA inactivation of approximately 1.5 log10. The results are similar to inactivation efficacy of household bleach when used at similar free available chlorine concentrations. Our work demonstrates the potential of ECO solutions, generated onsite, to be used for surface disinfection.

Background: Use of engineered nanoparticles (NPs) in consumer products is resulting in NPs in drinking water sources. Subsequent NP breakthrough into treated drinking water is a potential exposure route and human health threat., Objectives: In this study we investigated the breakthrough of common NPs--silver (Ag), titanium dioxide (TiO2), and zinc oxide (ZnO)--into finished drinking water following conventional and advanced treatment., Methods: NPs were spiked into five experimental waters: groundwater, surface water, synthetic freshwater, synthetic freshwater containing natural organic matter, and tertiary wastewater effluent. Bench-scale coagulation/flocculation/sedimentation simulated conventional treatment, and microfiltration (MF) and ultrafiltration (UF) simulated advanced treatment. We monitored breakthrough of NPs into treated water by turbidity removal and inductively coupled plasma-mass spectrometry (ICP-MS)., Results: Conventional treatment resulted in 2-20%, 3-8%, and 48-99% of Ag, TiO2, and ZnO NPs, respectively, or their dissolved ions remaining in finished water. Breakthrough following MF was 1-45% for Ag, 0-44% for TiO2, and 36-83% for ZnO. With UF, NP breakthrough was 0-2%, 0-4%, and 2-96% for Ag, TiO2, and ZnO, respectively. Variability was dependent on NP stability, with less breakthrough of aggregated NPs compared with stable NPs and dissolved NP ions., Conclusions: Although a majority of aggregated or stable NPs were removed by simulated conventional and advanced treatment, NP metals were detectable in finished water. As environmental NP concentrations increase, we need to consider NPs as emerging drinking water contaminants and determine appropriate drinking water treatment processes to fully remove NPs in order to reduce their potential harmful health outcomes.

Magnetic ion exchange (MIEX) pretreatment has been increasingly employed by water treatment plants for removal of dissolved organic carbon (DOC). In this study, the effects of MIEX pretreatment on low pressure membrane filtration of natural surface water were investigated under different feedwater qualities, membrane properties, and MIEX dosing conditions. Regardless of feedwater DOC, moderate decrease in the total and hydraulically irreversible fouling was observed for a polyvinylidene fluoride (PVDF) microfiltration membrane and a polyethersulfone ultrafiltration (UF) membrane after MIEX pretreatment, which was coincident with moderate removals of high molecular weight DOC in the feedwaters. Comparatively, the fouling of a PVDF UF membrane did not decrease after MIEX pretreatment, revealing the impact of membrane properties on membrane fouling in the presence of MIEX pretreatment. Reuse of virgin or regenerated MIEX resulted in similar membrane fouling as observed with single use of the virgin MIEX. The level of DOC removal by MIEX was similar to the removal of MS2 bacteriophage spiked in the feedwater, suggesting a potential similarity in the removal of organic and microbial particles. In conclusion, MIEX pretreatment was effective for DOC removal, but less effective in controlling short-term membrane fouling or removing viruses., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

This study used green fluorescent protein (GFP)-expressing Aspergillus fumigatus conidia to compare quantitative PCR (qPCR) enumeration with direct epifluorescent microscopic filter counts of conidia collected on filters in a test chamber. In separate experiments this study initially compared white versus fluorescent light microscopy for counting A. fumigatus conidia, then compared fluorescent microscopy counting of corresponding filter halves, and finally compared qPCR enumeration to counting by fluorescent light microscopy. The use of GFP-expressing conidia with epifluorescent microscopy yielded significantly higher conidia counts (p = 0.026, n = 41, mean of 4.1 conidia per counting field) and 40% faster counting times when compared to conventional counting using white light microscopy. GFP-expressing conidia were aerosolized in a test chamber and collected onto filters. Filters were divided in half and GFP-expressing conidia enumerated. There was no significant difference in the average conidia count per field between corresponding filter halves (p = 0.3, n = 9 filters, mean of 7.8 conidia per counting field). Thus, one filter half could be counted optically and would provide a reliable estimate of filter loading of the corresponding half, which could then be analyzed by qPCR. Filters (n = 38) loaded with GFP conidia in the aerosol chamber were divided in half and analyzed by either fluorescent microscopy or qPCR. The estimated filter loadings ranged from 15-30,000 conidia per filter. There was a linear relationship with a nearly 1:1 ratio between qPCR and direct microscopic estimates of filter loading (y = 1.06x + 404; R(2) = 0.91) showing that the outlined qPCR analysis method is in agreement with an external reference method and is reliable for enumerating A. fumigatus conidia collected on filters. The comparative data derived using GFP-expressing conidia confirmed that qPCR provides sensitive and accurate quantification of DNA from airborne conidia collected on filters.

Background: The role of environmental surface contamination in the propagation of norovirus outbreaks is unclear. An outbreak of acute gastroenteritis was reported among residents of a 240-bed veterans long-term-care facility., Objectives: To identify the likely mode of transmission, to characterize risk factors for illness, and to evaluate for environmental contamination in this norovirus outbreak., Methods: An outbreak investigation was conducted to identify risk factors for illness among residents and employees. Stool and vomitus samples were tested for norovirus by reverse transcription polymerase chain reaction (RT-PCR). Fourteen days after outbreak detection, ongoing cases among the residents prompted environmental surface testing for norovirus by RT-PCR., Results: One hundred twenty-seven (52%) of 246 residents and 84 (46%) of 181 surveyed employees had gastroenteritis. Case-residents did not differ from non-case-residents by comorbidities, diet, room type, or level of mobility. Index cases were among the nursing staff. Eight of 11 resident stool or vomitus samples tested positive for genogroup II norovirus. The all-cause mortality rate during the month of the outbreak peak was significantly higher than the expected rate. Environmental surface swabs from case-resident rooms, a dining room table, and an elevator button used only by employees were positive for norovirus. Environmental and clinical norovirus sequences were identical., Conclusion: Extensive contamination of environmental surfaces may play a role in prolonged norovirus outbreaks and should be addressed in control interventions.