Skip to main content

Military Health System

Important Notice about Pharmacy Operations

Change Healthcare Cyberattack Impact on MHS Pharmacy Operations. Read the statement to learn more. 

Surveillance Snapshot: Norovirus Outbreaks in Military Forces, 2015–2019

Image of Surveillance Snapshot: Norovirus Outbreaks in Military Forces, 2015–2019. Surveillance Snapshot: Norovirus Outbreaks in Military Forces, 2015–2019

Norovirus (NoV) infections are a leading cause of acute gastroenteritis outbreaks in both the U.S. and worldwide.1 Although most cases of NoV illness are mild and self-resolving, NoV outbreaks can cause significant morbidity in military personnel and have a significant operational impact on affected units.2,3

NoV outbreaks are difficult to prevent because of several characteristics. NoVs are highly contagious and transmitted through multiple routes, including person-to-person direct contact and exposure to contaminated food, water, aerosols, and fomites. NoVs have demonstrated long-term stability in the environment and resistance to temperature extremes and standard disinfection methods. Human infections with NoV are associated with a prolonged shedding period that promotes secondary transmission. Finally, previous NoV infection often does not confer lasting immunity to reinfection with the same NoV strain or to different strains.4

Previously, the MSMR has summarized published reports of NoV outbreaks in military forces.5,6 This update captures NoV outbreak reports in military forces published in the 5-year period between 2015 and 2019 (Table).7–13 The surveillance period included the years 2015 and 2016 (covered in a previous report) in order to identify NoV outbreak reports published since the last MSMR summary. Attack rates are provided when explicitly stated or when they could be derived from the data provided in published reports. This summary includes only outbreaks in military settings where the authors explicitly reported NoVs as a primary cause of the outbreak.

Several of the published reports documented significant operational impacts due to the NoV outbreak. Notably, the Camp Arifjan outbreak (and the public health response to contain it) resulted in the shutdown of a key personnel transit station in the U.S. Central Command for approximately 10 days,13 while the 2016 outbreak among French military personnel resulted in the cancellation of a field exercise because of a lack of personnel able to participate.11

The number of military-associated NoV outbreaks reported in peer-reviewed literature likely represents only a small fraction of all NoV outbreaks in military populations. During the surveillance period in this update, several large, military-associated NoV outbreaks were also reported in the press. Notable examples include a 2017 NoV outbreak originating in base child care centers at Hurlburt Field (the headquarters of the Air Force's 1st Special Operation Wing) that resulted in more than 100 cases14 and a 2019 outbreak at the U.S. Air Force Academy that affected about 400 cadets.15 Military enteric disease surveillance programs also routinely identify NoV outbreaks that are not published in the peer-reviewed literature. For example, between 2011 and 2016, the Naval Health Research Center's Operational Infectious Disease Directorate identified 18 NoV GI- and 26 NoV GII-associated outbreaks in U.S. military recruits.16 This finding highlights the importance of enteric disease surveillance programs in accurately quantifying the burden of NoV outbreaks in military populations.

References

  1. Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention. Updated norovirus outbreak management and disease prevention guidelines. MMWR Recomm Rep. 2011;60(RR-3):1–18.
  2. Delacour H, Dubrous P, Koeck JL. Noroviruses: a challenge for military forces. J R Army Med Corps. 2010;156(4):251–254.
  3. Queiros-Reis L, Lopes-João A, Mesquita JR, Penha-Goncalves C, Nascimento MSJ. Norovirus gastroenteritis outbreaks in military units: a systematic review [published online ahead of print 13 May 2020]. BMJ Mil Health.
  4. Glass RI, Parashar UD, Estes MK. Norovirus gastroenteritis. N Engl J Med. 2009;361(18):1776–1785.
  5. Armed Forces Health Surveillance Center. Historical perspective: norovirus gastroenteritis outbreaks in military forces. MSMR. 2011;18(11):7–8.
  6. Armed Forces Health Surveillance Branch. Surveillance snapshot: Norovirus outbreaks among military forces, 2008–2016. MSMR. 2017;24(7):30–31.
  7. Lopes-João A, Mesquita JR, de Sousa R, Oleastro M, Penha-Gonçalves C, Nascimento MSJ. Acute gastroenteritis outbreak associated to norovirus GI.9 in a Portuguese army base. J Med Virol. 2017;89(5):922–925.
  8. Neo FJX, Loh JJP, Ting P, et al. Outbreak of caliciviruses in the Singapore military, 2015. BMC Infect Dis. 2017;17(1):719.
  9. Lopes-João A, Mesquita JR, de Sousa R, et al. Country-wide surveillance of norovirus outbreaks in the Portuguese Army, 2015–2017. J R Army Med Corps. 2018;164(6):419–422.
  10. Watier-Grillot S, Boni M, Tong C, et al. Challenging investigation of a norovirus foodborne disease outbreak during a military deployment in Central African Republic. Food Environ Virol. 2017;9(4):498–501.
  11. Sanchez MA, Corcostégui SP, De Broucker CA, et al. Norovirus GII.17 outbreak linked to an infected post-symptomatic food worker in a French military unit located in France. Food Environ Virol. 2017;9(2):234–237.
  12. Lopes-João A, Mesquita JR, de Sousa R, Oleastro M, Penha-Gonçalves C, Nascimento MSJ. Simultaneous norovirus outbreak in three Portuguese army bases in the Lisbon region, Dec. 2017 [published online ahead of print 4 July 2019]. J R Army Med Corps. 2019;jramc-2019-001242.
  13. Kebisek J, Richards EE, Buckelew V, Hourihan MK, Finder S, Ambrose JF. Norovirus outbreak in Army service members, Camp Arifjan, Kuwait, May 2018. MSMR. 2019;26(6):8–13.
  14. Thompson J. More than 100 norovirus cases at Hurlburt. North West Florida Daily News. 16 Dec. 2017. https://www.nwfdailynews.com/news/20171216/more-than-100-norovirus-cases-at-hurlburt. Accessed 12 April 2020.
  15. Roeder T. Hundreds of Air Force Academy cadets sickened in norovirus outbreak. Colorado Springs Gazette. 20 Nov. 2019. https://gazette.com/military/hundreds-of-air-forceacademy-cadets-sickened-in-norovirus-outbreak/article_118b372a-0be7-11ea-8384-6f631e8afc31.html. Accessed 19 April 2020.
  16. Brooks KM, Zeighami R, Hansen CJ, McCaffrey RL, Graf PCF, Myers CA. Surveillance for norovirus and enteric bacterial pathogens as etiologies of acute gastroenteritis at U.S. military recruit training centers, 2011–2016. MSMR. 2018;25(8):8–12.

TABLE. Reported NoV outbreaks in military forces, 2015–2019

You also may be interested in...

Article
May 1, 2019

Absolute and relative morbidity burdens attributable to various illnesses and injuries, active component, U.S. Armed Forces, 2018

A U.S. naval officer listens through his stethoscope to hear his patient’s lungs at Camp Schwab in Okinawa, Japan in 2018. (Photo courtesy of U.S. Marine Corps) photo by Lance Cpl. Cameron Parks)

In 2018, mental health disorders accounted for the largest proportions of the morbidity and healthcare burdens that affected the pediatric and younger adult beneficiary age groups. Among adults aged 45–64 years, musculoskeletal diseases accounted for the most morbidity and healthcare burdens, and among adults aged 65 years or older, cardiovascular ...

Article
May 1, 2019

Absolute and relative morbidity burdens attributable to various illnesses and injuries, non-service member beneficiaries of the Military Health System, 2018

A senior airman of 366th Medical Support Squadron pediatric clinic checks vitals of the child of its service member at Mountain Home Air Force Base in Idaho. (Photo courtesy of U.S. Air Force)

In 2018, mental health disorders accounted for the largest proportions of the morbidity and healthcare burdens that affected the pediatric and younger adult beneficiary age groups. Among adults aged 45–64 years, musculoskeletal diseases accounted for the most morbidity and health care burdens, and among adults aged 65 years or older, cardiovascular ...

Article
Apr 1, 2019

Update: Exertional Rhabdomyolysis, Active Component, U.S. Armed Forces, 2014–2018

U.S. Marines sprint uphill during a field training exercise at Marine Corps Air Station Miramar, California. to maintain contact with an aviation combat element, teaching and sustaining their proficiency in setting up and maintaining communication equipment.  (Photo Courtesy: U.S. Marine Corps)

Among active component service members in 2018, there were 545 incident diagnoses of rhabdomyolysis likely due to exertional rhabdomyolysis, for an unadjusted incidence rate of 42.0 cases per 100,000 person-years. Subgroup-specific rates in 2018 were highest among males, those less than 20 years old, Asian/Pacific Islander service members, Marine ...

Article
Apr 1, 2019

Update: Exertional Hyponatremia, Active Component, U.S. Armed Forces, 2003–2018

Drink water the day before and during physical activity or if heat is going to become a factor. (Photo Courtesy: U.S. Air Force)

From 2003 through 2018, there were 1,579 incident diagnoses of exertional hyponatremia among active component service members, for a crude overall incidence rate of 7.2 cases per 100,000 person-years (p-yrs). Compared to their respective counterparts, females, those less than 20 years old, and recruit trainees had higher overall incidence rates of ...

Article
Apr 1, 2019

Incidence, Timing, and Seasonal Patterns of Heat Illnesses During U.S. Army Basic Combat Training, 2014–2018

U.S. Marines participate in morning physical training during a field exercise at Marine Corps Base Camp Pendleton, California. (Photo Courtesy: U.S. Marine Corps)

Risk factors for heat illnesses (HIs) among new soldiers include exercise intensity, environmental conditions at the time of exercise, a high body mass index, and conducting initial entry training during hot and humid weather when recruits are not yet acclimated to physical exertion in heat. This study used data from the Defense Health Agency’s ...

Article
Apr 1, 2019

Update: Heat Illness, Active Component, U.S. Armed Forces, 2018

Drink water the day before and during physical activity or if heat is going to become a factor. (Photo Courtesy: U.S. Air Force)

In 2018, there were 578 incident diagnoses of heat stroke and 2,214 incident diagnoses of heat exhaustion among active component service members. The overall crude incidence rates of heat stroke and heat exhaustion diagnoses were 0.45 cases and 1.71 cases per 1,000 person-years, respectively. In 2018, subgroup-specific rates of incident heat stroke ...

Article
Apr 1, 2019

Modeling Lyme Disease Host Animal Habitat Suitability, West Point, New York

A deer basks in the morning sun at Joint Base San Antonio-Fort Sam Houston, Texas.  (Photo Courtesy: U.S. Air Force)

As the most frequently reported vector-borne disease among active component U.S. service members, with an incidence rate of 16 cases per 100,000 person-years in 2011, Lyme disease poses both a challenge to health care providers in the Military Health System and a threat to military readiness. Spread through the bite of an infected blacklegged tick, ...

Article
Mar 1, 2019

Testosterone Replacement Therapy Use Among Active Component Service Men, 2017

Image of Marines carrying a wooden log for physical fitness. Click to open a larger version of the image.

This analysis summarizes the prevalence of testosterone replacement therapy (TRT) during 2017 among active component service men by demographic and military characteristics. This analysis also determines the percentage of those receiving TRT in 2017 who had an indication for receiving TRT using the 2018 American Urological Association (AUA) clinical ...

Article
Mar 1, 2019

Brief Report: Male Infertility, Active Component, U.S. Armed Forces, 2013–2017

Sperm is the male reproductive cell  Photo: iStock

Infertility, defined as the inability to achieve a successful pregnancy after 1 year or more of unprotected sexual intercourse or therapeutic donor insemination, affects approximately 15% of all couples. Male infertility is diagnosed when, after testing both partners, reproductive problems have been found in the male. A male factor contributes in part ...

Article
Mar 1, 2019

Sexually Transmitted Infections, Active Component, U.S. Armed Forces, 2010–2018

Anopheles merus

This report summarizes incidence rates of the 5 most common sexually transmitted infections (STIs) among active component service members of the U.S. Armed Forces during 2010–2018. Infections with chlamydia were the most common, followed in decreasing order of frequency by infections with genital human papillomavirus (HPV), gonorrhea, genital herpes ...

Article
Mar 1, 2019

Vasectomy and Vasectomy Reversals, Active Component, U.S. Armed Forces, 2000–2017

Sperm is the male reproductive cell  Photo: iStock

During 2000–2017, a total of 170,878 active component service members underwent a first-occurring vasectomy, for a crude overall incidence rate of 8.6 cases per 1,000 person-years (p-yrs). Among the men who underwent incident vasectomy, 2.2% had another vasectomy performed during the surveillance period. Compared to their respective counterparts, the ...

Article
Feb 1, 2019

Update: Incidence of Glaucoma Diagnoses, Active Component, U.S. Armed Forces, 2013–2017

Glaucoma

Glaucoma is an eye disease that involves progressive optic nerve damage and vision loss, leading to blindness if undetected or untreated. This report describes an analysis using the Defense Medical Surveillance System to identify all active component service members with an incident diagnosis of glaucoma during the period between 2013 and 2017. The ...

Last Updated: July 11, 2023
Follow us on Instagram Follow us on LinkedIn Follow us on Facebook Follow us on X Follow us on YouTube Sign up on GovDelivery