Norovirus Waterborne Outbreak in Chalkidiki, Greece, 2015: Detection of GI.P2_GI.2 and GII.P16_GII.13 Unusual Strains

Noroviruses, along with rotaviruses, are among the leading causes of gastroenteritis worldwide and novel strains are periodically emerging. In August 2015, an unusual increase of gastroenteritis cases occurred in a touristic district in Kassandra peninsula, Chalkidiki, Northern Greece. Seven stool specimens from cases were tested positive for norovirus. Molecular investigation and phylogenetic analysis identified that there was co-circulation of norovirus GI.P2_GI.2 and the recombinant strain GII.P16_GII.13. A 1:1 case-control study conducted and showed that tap water consumption significantly associated with developing symptoms of gastroenteritis (odds ratio = 36.9, P = 0.018). The results of the epidemiological investigation, the co-circulation of two different norovirus strains, the information of a pipeline breakage at the water supply system before the onset of cases, and reports on flooded wells and sewage overflow, indicated the possibility of water contamination by sewage during the pipeline breakage leading to a large outbreak with a peak at 10 August and a possible secondary person-to-person transmission after the 16th of August. Norovirus GI.P2_GI.2 strains are rarely reported in Europe, while it is the first time that infection from the recombinant strain GII.P16_GII.13 is recorded in Greece.