For the March break and Easter, we went back to the beautiful island of St.Maarten, where we purchased a condo in the Sonesta Great Bay several years ago. Since the resort decided suddenly and unilaterally a couple of years ago changing to an “adults only” hotel, the condo and time share owners with young children like us have to either not to go there and forget about their initial purpose and investment, or to stay in the condo and not use the hotel facilities as it is prohibited with family with children. But we kept going as we love the island and since we could go to the sister resort of Sonesta Maho daily and still enjoy our vacation somehow.

 This time when we arrived on March 15 for a 2 weeks stay, we were warned about a “stomach bug” on the island, mostly in the Maho resort. So we refrained to go to Maho and locked ourselves in our condo and satisfied ourselves with only the visual pleasure of the beautiful scenery and the ocean. After about a week, and reassurance from the hotel managements that there have not been any new cases for a few days, we decided to take our three young kids out of the condo to the Sonesta Maho, where kids and family are welcome. We could not believe how quiet was the resort that usually specially during the March breaks are stormed with families and young children! We stepped in the restaurant after sanitizing our hands several times, per recommendation of the hotel management. The restaurant that was always very busy, looked like a ghost restaurant and obsolete like after an extra-terrestrial attack on earth, very quiet with only us and a few others. We decided to sit outside in the open area by the ocean to be safer from the bug if still around. Inside the buffet restaurant, the foods were served to us by the staff wearing gloves and not letting us touch the food or the cutleries. All this seemed very suspicious and smelled the danger, but we relied on the reassurance of the hotel managements that there have been no new cases and the resort is safe as long as we sanitize our hands that we did several times. Long story short, we went on the next day, March 22 as well and enjoyed the resort and the beach, and watching the landing and takeoffs of the planes in the Maho short runway by the ocean.

 The night of March 22, was nightmarish, as first our daughter started with projectile vomiting repeatedly all night long, shivering and fevering, sobbing in fear of doom and dying. Then our youngest son, became sick the same, vomited everywhere, scared to die, then my wife who was courageously cleaning after them, started to throw up violently that frightened all of us, including me and my middle son, barricading ourselves in another room to be at least the two safe, but oblivious of the fact that the bug has already been in all our bodies and it was just a matter of time to show its symptoms! I could not sleep all night long, worried of what is going to happen to us in our vacation that supposed to be all in peace and fun. I had already read about the bug, a virus called “norovirus” or “vomit bug” that you will read in detail soon after the conclusion of my personal encounter. The night passed relatively uneventful other than my worries for the two of us in the barricade, but all of a sudden in early morning, my boy jumped off the bed in nausea, ran to the washroom and locked himself in, kept vomiting in the toilet for at least half an hour, not letting me who was scared, in as he is a big boy with pride. This scenario happened again three or four times until the vomits stopped around noon. After that he had diarrhea all day long, spending all of the Wednesday, March 23rd between the washroom and the bed. Shortly after him, in the morning, while I was thinking how I have been exempted by the mercy of the virus, that an instantaneous nausea overcame me so ran to the washroom and had a projectile bloody looking vomit.  We all did not recover until the third day and fortunately survived this microbial invasion as there are cases of death as you will read in the following.

 The vomit bug or Norovirus is a genus of Norwalk virus, named after Norwalk, Ohio in US, where an acute outbreak of gateroenteritis occurred among children in 1968. This virus is the most common cause of viral gastero-enteritis in humans, transmitted by fecally contaminated food or water, by person-to-person contact and via aerosolization of vomited virus and subsequent contamination of surfaces. Norovirus is a very tiny, un-enveloped RNA virus possessing the highest mutation rate even among other RNA viruses. Human and mammals serve as the natural host of Noroviurs, the leading cause of foodborne gasetroenteritis worldwide, affecting over 125 million people with over 200,000 deaths each year mostly in less developed countries and in the very young, elderly and immune-suppressed. (1-4) Norovirus infection is characterized by nausea, vomiting, watery diarrhea, abdominal pain, lethargy, weakness, muscle aches, headaches, and low-grade fever. The disease is usually self-limiting in a few days, and severe illness is rare, but immunity is usually incomplete, temporary and not beyond a few years.

 In contrary to what the hotel management recommended to sanitize our hands and hand sanitizers were all around, Norovirus could only be eradicated by either sufficient heating or by chlorine-based disinfectants and polyquaternary amines, and not alcohols, detergents, or usual hand sanitizers. The Norovirus can survive for long periods outside a human host depending on the surface and temperature conditions: it can stay for weeks on hard surfaces, and up to twelve days on contaminated fabrics, and it can survive for months, maybe even years in contaminated still water. Outbreaks of Norovirus infection often occur in closed or semiclosed communities, such as long-term care facilities, overnight camps, hospitals, schools, prisons, dormitories, and cruise ships, where the infection spreads very rapidly either by person-to-person transmission or through contaminated food. Many Norovirus outbreaks have been traced to food that was handled by one infected person, and Norovirus is responsible for 50% of all foodborne outbreaks of gastroenteritis in the United States. (5-7)

Noroviruses are transmitted directly from person to person and indirectly via contaminated water and food. They are extremely contagious, and fewer than twenty virus particles can cause an infection. Transmission can be aerosolized when those stricken with the illness vomit, and can be aerosolized by a toilet flush when vomit or diarrhea is present; infection can follow eating food or breathing air near an episode of vomit, even if cleaned up. The viruses continue to be shed after symptoms have subsided and shedding can still be detected many weeks after infection. Shelfish and salad ingredients are the foods most often implicated in Norovirus outbreaks, that were actually serving at the Sonesta Maho where we ate. Since there is no treatment, but only preventive measures for Norovirus, Centers for Disease Control and Prevention (CDC) has published a guideline addressing strategies for the prevention and control of Norovirus that includes, infected persons identification and isolations, transfer and facility closure, examination of food handlers, environmental cleaning, proper communication and notification. (8-9)

 Cruise ships are the main non-medical facilities that the virus could affect the healthy passengers whose fun trip would be disrupted terminally. According to the CDC report, in recent years there have been the following number of infected passengers of cruise ships: in 2010, 7101, in 2012, 5542, in 2014, 3530 and I 2015, 2570 passengers. This year 2016 that has passed only three months, Norovirus has already affected 8 cruise ships as following: Crown Princess in January, Oceania Riviera in February, Ocean Princess, Anthem of the Seas, Carnival Sunshine throughout February and March, Sliver Spirit, Norvegian Gem, and Oceania Riviera in March, according to CDC report. (10)

 Invasion of Norovirus in the island of St. Maarten where we consider our vacation home, has been going on since at least mid-February according the Saint Martin News Network (smn-news.com). But the Sonesta Maho management, then the ministry of health of the island and their Collective Preventive Services (CPS) in a report on March 7, 2016 about the infection in Sonesta Maho declare that “a sudden spike in guests complaining of mainly vomiting and a few cases accompanied with diarrhea, among approximately 200 tourists that arrived from Canada around February 17…then a sudden increase in gastroenteritis was noted again among some overseas students that had checked-in on February 24 with the majority checking in on February 25… It can be concluded based on the ministries investigation that this was not an outbreak originating in food or drinking water, but rather by external intrusion stimulated by cross contamination.” We don’t know how St. Maarten ministry of health and their CPS through what detail investigation and examinations concluded the safety of water and food in Sonesta Maho and reported the epidemic infection that still to this day is going on in the resort has been the result of external intrusion and cross contamination that the hotel blames it on the tourists from Canada and some overseas students! (11)

 At the same time the cruise ships this year as always have been constantly contaminated with Norovirus per reports of many cruise news websites, e.g. cruiseminus.com, cruiselawnews.com, even major news broadcasts such as abc.net, cbc.ca and cnn.com. In fact the passengers of cruise ships hop on different islands, visit many places, drink and eat in bars and restaurants including hotels, specially Sonesta Great Bay, where we stay and have our condo and Sonesta Maho, where it is a major tourist sightseeing for the island airport, and where we ate only two days and fell sick immediately. According to the cruiselawnews.com, in the month of March alone, 124 passengers had been infected on Oceania Riviera, over 300 on Golden Princess, 137 on Norwegian Gem among others.

 After a couple of months of epidemic from February throughout March in St.Maarten mostly Sonesta Maho resort and hotel, the authorities of the island refused the docking of Norvegian Gem cruise ship that was infected with more than 130 passengers. Up to March 25, 2016 there have been report of complaints about the cruise ship from infected passengers, including a female lawyer, a breast cancer survivor who took the trip as a celebration of her survival, but was infected seriously and her complaints to the cruise ship had been unfruitful, so she is taking legal action against the vessel. (cruiselawnews.com)

 No matter the source of infection that usually originates in the food, water and food handling workers, according to CDC preventing measures, the infected person has be isolated and in case of workers properly removed from the site, then the source has to be identified promptly, all the food handling personnel need to be examined, and meanwhile to be relatively safe, the restaurants have to be temporarily closed and foods have to be served in the rooms. (12-13) In a metanalysis of all studies of Norovirus outbreaks on cruise ships published from January 1990 to July 2013 that were written in English, describing a total of 127 outbreaks, by Bert et al. (14) revealed infection up to 74% of the embarked passengers. So the matter is a major health concern, of financial cost and burden to the tourist industry particularly the cruise ships, and above all emotional and psychological trauma and suffering burden to the healthy passengers and tourists who end up in misery and ruining of their vacations, with often no compensations from the cruise ships, hotels and other tourist industry. Surprisingly the popular trip advisory websites and media such as “tripadvisor” and the cruise ships, the hotels and else alike do not advise and warn the consumers for the fear of loss of profit!

 In the majority of the studies and investigations, stool samples and/or serum specimens from ill passengers have been collected and tested for virus identification confirmation, while food samples that are the main source of the virus and outbreaks, have been usually difficult to obtain from the facilities so at the end, the primary source of an outbreak often goes undetected. (13) therefore Bert and colleagues (14) recommend strong need for the immediate monitoring and implementation of preventive measures in semi-closed communities, such as cruise ships. But despite all these sufferings, the cruise lines and the tourist facilities such as Sonesta Maho that is still totally infected continue to run and no health authorities step up to conduct immediate and proper preventive measures, specially on tropical islands that survive on tourism and the multi-billion dollars cruise lines industry who are not willing to lose a penny!

 In fact as detailed in many articles on this site, the long-term impact and latent manifestations of infections such as Norovirus, no matter how acute and self-limiting, are hard to predict! Thus far there has been a report of linking Crohn’s disease in the most recent genome-wide association studies to the FUT2 W143X mutation (resulting in asymptomatic norovirus infection). (15) Therefore those un-infected in an infected environment such as cruise ships or hotels who may be of %20 of Caucasian descent and do not typically show the signs and symptoms of the infection, cannot be happy, as an un-identified long-term impact may await them!

Norovirus actually is one of the most virulent viruses on earth, so the cause of most human gasteronteritis, acting only in 1-2 days to show its acute damage. But as me and my wife still feel some abdominal discomfort, and at times mild nausea, dizziness and fatigue, despite overcoming the acute symptoms, we feel the virus is still in our bodies. This tiny virus seems to be so intelligent by its nature of survival and its power of commonality that its cause of projectile vomiting is purposeful to spread itself all over, even flushing toilets after the vomit, causes its further spread. The short-lasting immunity of this virus, 6 months to 2 years, is a testimony and strong evidence that the virus has laid latent in the bodies of infected victims, awaiting to act its adversary one day soon again!

Oblivion to all the above scientific facts and more, that can not be detailed here due to space limit, the cruise ships and hotels such as Sonesta Maho do not even follow up the basic official health recommendation guidelines for prevention and further spread of the epidemic of Noroviurs. Moreover the prevalence of the infection is far under-rated and reported as due to short-living and so called “self-limiting” of the illness, majority of inflicted individuals take it as “food poisoning” and do not report, also the medical personnel may evaluate it as such, while the authorities of the infected facilities, such as cruise ships and hotels who are well aware of the fact, would ignore it to save their business. Believing that hand sanitizing would kill the virus and prevent the subjects from the infection, as we were recommended by the hotel managements, is total ignorance as the virus as detailed above, is only eradicated by sufficient heating, chlorine-based disinfectants and polyquaternary amines. Furthermore, how the cruise ships and hotels like Sonesta Maho, eradicate the virus from all the hotel surfaces, including the fabrics and furniture all over their facilities. How the food that could be the main source of the virus is inspected and infected items removed? How the food handling staff are examined and the infected ones are removed from the facilities? All these in fact need quite some time to be conducted properly and requires the facilities to be closed temporarily for all the identification, cleaning, eradication, and so forth, that neither the cruise ships nor the hotels will ever do so unless are enforced by the health and government authorities.   

Dr.Mostafa Showraki, MD, FRCPC                                                                  Lecturer, School of Medicine, University of Toronto,Author: “ADHD:Revisited” Book/ “adhdrevisited.com”/”medicinerevisited.com”

 References:

1. Goodgame R (2006). “Norovirus gastroenteritis”. Curr Gastroenterol Rep 8 (5): 401–08.
2. Said MA, Perl TM, Sears CL (November 2008). “Healthcare epidemiology: gastrointestinal flu: norovirus in health care and long-term care facilities”. Clinical Infectious Diseases 47 (9): 1202–8.
3. Kirk MD, Pires SM, Black RE, Caipo M, Crump JA, Devleesschauwer B, Döpfer D, Fazil A, Fischer-Walker CL, Hald T, Hall AJ, Keddy KH, Lake RJ, Lanata CF, Torgerson PR, Havelaar AH, Angulo FJ. World Health Organization Estimates of the Global and Regional Disease Burden of 22 Foodborne Bacterial, Protozoal, and Viral Diseases, 2010: A Data Synthesis.PLoS Med. 2015 Dec 3;12(12):e1001921.
4. Debbink K, Lindesmith LC, Donaldson EF, Baric RS (2012). “Norovirus Immunity and the Great Escape”. PLoS Pathog 8 (10): e1002921.
5. Koopmans M, Duizer E (2004). Foodborne viruses: an emerging problem. J. Food Microbiol. 90 (1): 23–41.
6. Widdowson MA, Sulka A, Bulens SN, Beard RS, Chaves SS, Hammond R, Salehi ED, Swanson E, Totaro J, Woron R, Mead PS, Bresee JS, Monroe SS, Glass RI (2005). Norovirus and foodborne viruses, United States. Emerging Infect. Dis. 11 (1): 95–102.
7. Ahmed SM, Hall AJ, Robinson AE, et al. (August 2014). “Global prevalence of norovirus in cases of gastroenteritis: a systematic review and meta-analysis”. Lancet Infect Dis 14 (8): 725–30.
8. Shieh Y, Monroe SS, Fankhauser RL, Langlois GW, Burkhardt W, Baric RS (2000).Detection of Norwalk-like virus in shellfish implicated illness. Infect. Dis. 181 (Suppl 2): S360–6.
9. D’Souza DH, Sair A, Williams K, Papafragkou E, Jean J, Moore C, Jaykus L (2006). “Persistence of caliciviruses on environmental surfaces and their transfer”. International Journal of Food Microbiology 108 (1): 84–91.
10. Outbreak Updates for International Cruise Ships.cdc.gov.
11. CPS concludes investigation into Norovirus outbreak. All Hotels to be instructed to have a Norovirus control plan. Smn-news.com. 07 March 2016.
12. Updated Norovirus Outbreak Management and Disease Prevention Guidelines.2011.cdc.gov.
13. MacCannell, T; Umscheid, CA; Agarwal, RK; Lee, I; Kuntz, G; Stevenson, KB (2011). “Guideline for the prevention and control of norovirus gastroenteritis outbreaks in healthcare settings”. Infection Control and Hospital Epidemiology 32 (10): 939–969.
14. Bert F, Scaioli G, Gualano MR, Passi S, Specchia ML, Cadeddu C, Viglianchino C, Siliquini R. Norovirus outbreaks on commercial cruise ships: a systematic review and new targets for the public health agenda.Food Environ Virol. 2014 Jun;6(2):67-74.
15. Chamaillard M, Cesaro A, Lober PE, Hober D. Decoding norovirus infection in Crohn’s disease.Inflamm Bowel Dis. 2014 Apr;20(4):767-70.