An Examination of Epidemiologic Patterns of Acute Gastroenteritis and Potential Risk Factors in a Leisure Setting Público

Abstract

Background: Travel-associated enteric infections, including traveller's diarrhea and acute gastroenteritis (AGE), are not an uncommon occurrence for travelers. Research on risks factors for AGE in hotel, resort, and cruise ship settings could help guide recommendations to prevent further endemic and epidemic cases.

Objective: The goal of this analysis was to examine epidemiologic patterns of AGE and identify potential risk factors in 22 resorts across the globe owned by one company.

Methods: The study population included 4,739 cases of AGE, out of the 475,875 guests and approximately 23,524 staff at 22 resorts in 2015. In order to compare risk factors by time, duration of resort visits were classified into short and long stays (1-5 and 6-15 days, respectively). An unpaired t-test was used to compare the difference in attack rates between short and long stays at each resort. Linear regression was performed to examine the association between attack rate and potential risk factors.

Results: Although no outbreaks of AGE occurred in the study population, one of the main findings from this analysis was that guests at the resorts had a higher AGE attack rate than staff. (β=0.00149, p-value=<0.0001 for short stays and β=0.00109, p-value=0.0006 for long stays). Another major finding was a positive association between the day of symptom onset and the attack rate during long stays, meaning attack rates increased over the span of a travel package (β=0.00014, p-value=<0.0001). There was an overall higher percentage of cases and attack rate associated with summer.

Conclusion and Recommendations: Further research is needed to improve characterization of epidemiologic patterns of AGE in leisure settings. Advances in testing of norovirus diagnostics and improved identification of cases are top priorities. Recommended research opportunities specific to leisure settings include closer tracking of guest and staff hygienic practices and daily activities. Through increased research and implementation of evidence-based recommendations, resort settings can become a healthier environment for guests and staff.

Table of Contents

Chapter 1: Introduction and Literature Review.................................................1

A. Introduction and Rationale.........................................................................1

B. Problem Statement....................................................................................4

C. Literature Review.......................................................................................4

Waterborne Outbreaks in Leisure Settings.......................................................4

Outbreaks in Leisure Settings Associated with Environment Contamination or Person-to-Person Transmission............................................................................................................7

AGE Outbreaks on Cruise Ships.......................................................................9

E. Purpose Statement....................................................................................13

F. Research Questions...................................................................................13

G. Significance Statement..............................................................................15

Chapter 2: Methods.......................................................................................15

A: Definition of Terms...................................................................................15

B. Study Population.......................................................................................16

C. Analytic Approach.....................................................................................16

D. Instruments..............................................................................................19

E. Ethical Considerations...............................................................................19

Chapter 3: Results.........................................................................................19

Table 1: Characteristics of resorts in 22 resorts, 2015 (N=4,739)........................21

Table 2. Characteristics of cases in 22 resorts, 2015 (N=4,739)..........................22

Table 3. Linear regression coefficients modeling short stay attack rates as a function of AGE risk factors in 22 resorts, 2015.................................................................................................................24

Table 4. Linear regression coefficients modeling long stay attack rates as a function of AGE risk factors in 22 resorts, 2015.................................................................................................................26

Figure 1: Percent of case distribution by age in 22 resorts, 2015 (N=4,739).............28

Figure 2: Distribution of AGE cases by guests and staff in 22 resorts, 2015 (N=4,739)................29

Figure 3: AGE attack rates for guests and staff on short travel packages in 22 resorts, 2015.......29

Figure 4: AGE attack rates for guests and staff on long travel packages in 22 resorts, 2015.........30

Figure 5: Distribution of cases by resort, 22 resorts, 2015 (N=4,739)........................31

Figure 7: AGE attack rates by resort for long travel packages in 22 resorts, 2015........32

Figure 8: Distribution of cases by resort size, 22 resorts, 2015 (N=4,739)..................33

Figure 9: AGE attack rate for short stays by resort size, 22 resorts, 2015...................33

Figure 10: AGE attack rate for short stays by resort size, 22 resorts, 2015.................34

Figure 11: Distribution of AGE cases by month in 22 resorts, 2015 (N=4,739)............35

Figure 12: Distribution of AGE cases by season in 22 resorts, 2015 (N=4,739)............36

Figure 13: AGE attack rates on short stays by month in 22 resorts, 2015...................36

Figure 14: AGE attack rates on short stays by season in 22 resorts, 2015...................37

Figures 15: AGE attack rates on long stays by month in 22 resorts, 2015...................37

Figure 16: AGE attack rates on long stays by season in 22 resorts, 2015....................38

Figure 17: Distribution of cases by day of symptom onset relative to the start of the travel package (Day 0) in 22 resorts, 2015 (N=4,739)............................................................................................................40

Figure 18: AGE attack rates for short stays by day of symptom onset in 22 resorts, 2015.....40

Figure 19: AGE attack rates for long stays by day of symptom onset in 22 resorts, 2015......41

Figure 20: Distribution of cases by the day of case reporting relative to symptom onset in 22 resorts, 2015 (N=4,739).............................................................................................................42

Figure 21: AGE attack rate for short stays by the day of case reporting relative to symptom onset in 22 resorts, 2015....................................................................................................................43

Figure 22: AGE attack rate for long stays by the day of case reporting relative to symptom onset in 22 resorts, 2015....................................................................................................................43

Figure 23: Distribution of AGE cases by the distance between the residence room and the dining hall in 22 resorts, 2015 (N=4,739)............................................................................................................44

Figure 24: AGE attack rates by distance from residence room to dining hall for short stays in 22 resorts, 2015...................................................................................................................45

Figure 25: AGE attack rates by distance from residence room to dining hall for long stays in 22 resorts, 2015...................................................................................................................45

Chapter 4: Discussion..........................................................................................46

A: Summary of the Findings.................................................................................46

Notable Risk Factors............................................................................................46

Attack Rates: Guest versus Staff...........................................................................46

Attack Rate: Onset of Symptoms Relative to the Start of Travel Package..................47

Attack Rate: Temporality.....................................................................................48

Attack Rate: Length of Travel Package..................................................................48

Attack Rate: Resort Size.......................................................................................49

B: Strengths and Limitations................................................................................50

Chapter 5: Implications/Recommendations...........................................................51

A: Implementing the Results................................................................................51

B: Recommendations for Future Research..............................................................52

References...........................................................................................................54

About this Master's Thesis

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School	Rollins School of Public Health
Department	Hubert Department of Global Health
Degree	MPH
Submission	Master's Thesis
Language	English
Research Field	Health Sciences, Public Health Health Sciences, Epidemiology
Palabra Clave	Norovirus AGE
Committee Chair / Thesis Advisor	Moe, Christine L, Emory University
Partnering Agencies	Industrial or Commercial (for-profit) organization

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