Gosh what a controversy (Public Health England) PHE and the International Association of Athletics Federations (IAAF) have got themselves into over the outbreak of Norovirus at the London 2017 World Athletic Championships. The spokesperson from PHE, Dr Deborah Turbitt, said “PHE has been notified of a confirmed outbreak of Norovirus among people associated with the World Athletics Championships”.
It is reported in the media that around 30 athletes and associated people, all staying at the Tower Hotel near Tower Bridge, have been taken ill over the last few days. Several nationalities are involved including Irish, German, Canadian, Puerto Rican and Botswanan. But it is the Botswanan 200m and 400m gold medal hopeful, Isaac Makwala, who has caused the most controversy, not helped by the videoed eviction at the stadium door which has been played over and over on TV and the subsequent live debate on BBC Sport.
It is reported in the media that around 30 athletes and associated people, all staying at the Tower Hotel near Tower Bridge, have been taken ill over the last few days. Several nationalities are involved including Irish, German, Canadian, Puerto Rican and Botswanan. But it is the Botswanan 200m and 400m gold medal hopeful, Isaac Makwala, who has caused the most controversy, not helped by the videoed eviction at the stadium door which has been played over and over on TV and the subsequent live debate on BBC Sport.
Now I have none of the details regarding this particular outbreak but I’m going to discuss it anyway as a hypothetical outbreak scenario.
What is Norovirus and how is it spread?
Diarrhoea and vomiting is not a common cause of mortality among most people, however the old and frail or immunodeficient can die. The majority of cases are caused by viruses such as Norovirus and Rotavirus. The microorganisms that cause diarrhoea and vomiting are so infectious it is very easy for them to spread around large gatherings and healthcare settings unless precautions are taken. A major concern for an event like the World Athletic Championships is that once the participants return home they can rapidly disseminate the infection across the world. The athletes are unfortunate because the incidence of Norovirus is in fact 23% lower than the average for the same period compared to the last 5 years and yet they have still managed to acquire it.
Mode of Transmission
Norovirus is normally spread by the faecal-oral route; droplets can survive for several days outside of the body on objects and surfaces. In a patient with Norovirus each gram of stool contains approximately 10 million infectious doses of virus.
Incubation Period
Norovirus - 24-48 hours
Rotavirus - 24-72 hours
Period of Communicability
A person with gastroenteritis is most infectious from when their symptoms start until a couple of days after symptoms resolve, hence the 48 hour quarantine advice from PHE. Virus is often still detectable at low levels in stool after symptoms resolve, so ongoing effective hand hygiene is essential.
What is Norovirus and how is it spread?
Diarrhoea and vomiting is not a common cause of mortality among most people, however the old and frail or immunodeficient can die. The majority of cases are caused by viruses such as Norovirus and Rotavirus. The microorganisms that cause diarrhoea and vomiting are so infectious it is very easy for them to spread around large gatherings and healthcare settings unless precautions are taken. A major concern for an event like the World Athletic Championships is that once the participants return home they can rapidly disseminate the infection across the world. The athletes are unfortunate because the incidence of Norovirus is in fact 23% lower than the average for the same period compared to the last 5 years and yet they have still managed to acquire it.
Mode of Transmission
Norovirus is normally spread by the faecal-oral route; droplets can survive for several days outside of the body on objects and surfaces. In a patient with Norovirus each gram of stool contains approximately 10 million infectious doses of virus.
Incubation Period
Norovirus - 24-48 hours
Rotavirus - 24-72 hours
Period of Communicability
A person with gastroenteritis is most infectious from when their symptoms start until a couple of days after symptoms resolve, hence the 48 hour quarantine advice from PHE. Virus is often still detectable at low levels in stool after symptoms resolve, so ongoing effective hand hygiene is essential.
Click for larger image
What is an outbreak?
An outbreak is when there are two or more cases linked in time, place or person. A single infection can constitute an outbreak if the infection is significantly rare or unlikely in the particular situation e.g. malaria in a patient who has never left the UK. At the World Athletic Championships two cases have confirmed positive for Norovirus.
As events unfolded more athletes were afflicted, some athletes were put into quarantine and others forced to miss their events. Germany’s Neele Eckhardt collapsed at the triple jump heats on Saturday but took part in in Monday's final, finishing last. The Canadian Eric Gillis dropped out of Sunday’s marathon after about 20 miles. Ireland’s Thomas Barr was forced to withdraw from the 200m hurdles semi-final on Monday night, “my whole year has been focused on the world championships, and to not be able to go out and compete for Ireland today is beyond disappointing.” “I was one of the athletes in quarantine,” said Canadian sprinter Aaron Brown and another Botswanan, Onkabetse Nkobolo was also affected.
Michael Johnson (the former 200m and 400m world record holder) weighed in stating “if you collapse you’re OK but if you vomit you’re not OK?... What are the criteria? This is going to be one of those situations where the IAAF is going to realise it’s got it horribly wrong one way or the other, either by disqualifying this athlete from competition unnecessarily, or by not communicating clearly to him and his team why they’ve chosen to disqualify him.”
The IAAF announced a problem with illness on Sunday. Isaac Makwala had been seen being sick after getting off the team bus. “The IAAF were clearly on edge and didn't want it to spread, so when he [Isaac Makwala] presented himself as being ill, of course the IAAF had to go to their protocols, " BBC commentator Allison Curbishley (former 400m runner) said.
But it really gripped audiences as the Botswanan athlete publically dismissed his illness. “I was never tested!!” exclaims Isaac Makwala. Falcon Sedimo, chief executive of the Botswana national sports commission added to the debate, "there have been no medical tests at all, it's just generalised assumptions because of the outbreak of sickness and he [Isaac Makwala] has just one of those symptoms." The live debate on the BBC saw Paula Radcliffe ask “why they cannot confirm it by a blood test?” Exclaiming “if he is negative surely he should be allowed to race? …he's planning on staying in his lane! He's not planning on coming into close contact with anybody else!!”
Gosh these former athletes are all suddenly experts on infection, wouldn’t it be nice to get such media coverage to explain the truth!?
So is it fair to assume Isaac Makwala has Norovirus? Well, yes it is. In an outbreak setting you do not need to test everybody with the same symptoms to prove they have the same infection. Once you know what the infection is it is accepted practise to assume that all “linked” and symptomatic patients have the same cause. In this case they knew two linked athletes had Norovirus and therefore any other competitor or team member was diagnosed as having the same. This would be the same procedure for a ward or care home outbreak.
“His [Isaac Makwala’s] condition didn’t start at the medical room (7 Aug Monday),” Sedimo said. “It started before lunch yesterday (Sunday); it’s just that when he arrived at the medical room, medical experts made their own pronouncements.”
In fact the IAAF said the decision to withdraw him from the 200m heats last night (7 Aug Monday) and the 400m final today (8 Aug Tuesday) was made on the basis of a medical examination conducted in the warm-up medical centre by a qualified doctor on Monday (7 Aug) and recorded in the electronic medical record system of the championships. A copy of this medical record was given to a member of the Botswanan team’s medical staff following the examination.
The letter sent by the IAAF to all the teams is very clear and states “recommendations from Public Health England say the affected person must remain isolated for 48 hours after the last episode of vomiting or diarrhoea and therefore, the person will need to take their meals in their room.”
To answer Paula Radcliffe’s question about testing, no, blood cannot be tested. However, stool can be tested by PCR within a few hours BUT in this situation a negative test does not mean the athlete does not have Norovirus. All tests have false positives and false negatives as well as a minimum limit of detection. In an outbreak when someone has symptoms and a negative test the test is considered a false negative and the person still quarantined. In the rare situation when the person might genuinely not have Norovirus but are symptomatic (vomiting and diarrhoea) they are still likely to have another infectious cause which is contagious.
Are we too strict in the UK?
It has been mentioned that PHE have over reacted and been party poopers (no pun intended!). The British former 400m runner Dai Greene tweeted "I was really ill in the build-up [to the 2010 Commonwealth Games] in Delhi as were so many others. But nobody stopped us racing or tested us." Why do we test!? Should we care!!??
The assertion that, “if the situation arose again it would be dealt with very differently” concerns me greatly as I believe this is advocating outbreak management by social media. We need to resist the misinformation and base policy on sound judgement. Clearly it is very disappointing for athletes to miss out when they have trained so hard but think of the headlines if the 400m final only had 2 competitors competing as all the other athletes were sick having been knowingly exposed to a contagious virus in the semi-finals!? It has to be up to the integrity of the individual athlete to ensure they keep themselves and other competitors safe. Paula Radcliffe has rightly raised the issue that “if an athlete has the same symptoms later this week they may well keep it quiet." This may be true but it is not a responsible way to behave.
So in the end, Isaac Makwala’s quarantine period ended at 2pm 9 Aug but unfortunately by this time his race had already been won the evening before by Wayde Van Niekerk from South Africa. In my opinion PHE were 100% correct in their advice and action during the World Athletic Championships. This was a clear case of when having “the runs” at an athletics event was not a good thing!
Note: the hotel in this case has stated that investigations have confirmed that the hotel was not the source of the illness; they have stated “we have followed strict hygiene protocol, ensuring that those affected are not in contact with other guests and all public areas have been thoroughly sanitised.”
An outbreak is when there are two or more cases linked in time, place or person. A single infection can constitute an outbreak if the infection is significantly rare or unlikely in the particular situation e.g. malaria in a patient who has never left the UK. At the World Athletic Championships two cases have confirmed positive for Norovirus.
As events unfolded more athletes were afflicted, some athletes were put into quarantine and others forced to miss their events. Germany’s Neele Eckhardt collapsed at the triple jump heats on Saturday but took part in in Monday's final, finishing last. The Canadian Eric Gillis dropped out of Sunday’s marathon after about 20 miles. Ireland’s Thomas Barr was forced to withdraw from the 200m hurdles semi-final on Monday night, “my whole year has been focused on the world championships, and to not be able to go out and compete for Ireland today is beyond disappointing.” “I was one of the athletes in quarantine,” said Canadian sprinter Aaron Brown and another Botswanan, Onkabetse Nkobolo was also affected.
Michael Johnson (the former 200m and 400m world record holder) weighed in stating “if you collapse you’re OK but if you vomit you’re not OK?... What are the criteria? This is going to be one of those situations where the IAAF is going to realise it’s got it horribly wrong one way or the other, either by disqualifying this athlete from competition unnecessarily, or by not communicating clearly to him and his team why they’ve chosen to disqualify him.”
The IAAF announced a problem with illness on Sunday. Isaac Makwala had been seen being sick after getting off the team bus. “The IAAF were clearly on edge and didn't want it to spread, so when he [Isaac Makwala] presented himself as being ill, of course the IAAF had to go to their protocols, " BBC commentator Allison Curbishley (former 400m runner) said.
But it really gripped audiences as the Botswanan athlete publically dismissed his illness. “I was never tested!!” exclaims Isaac Makwala. Falcon Sedimo, chief executive of the Botswana national sports commission added to the debate, "there have been no medical tests at all, it's just generalised assumptions because of the outbreak of sickness and he [Isaac Makwala] has just one of those symptoms." The live debate on the BBC saw Paula Radcliffe ask “why they cannot confirm it by a blood test?” Exclaiming “if he is negative surely he should be allowed to race? …he's planning on staying in his lane! He's not planning on coming into close contact with anybody else!!”
Gosh these former athletes are all suddenly experts on infection, wouldn’t it be nice to get such media coverage to explain the truth!?
So is it fair to assume Isaac Makwala has Norovirus? Well, yes it is. In an outbreak setting you do not need to test everybody with the same symptoms to prove they have the same infection. Once you know what the infection is it is accepted practise to assume that all “linked” and symptomatic patients have the same cause. In this case they knew two linked athletes had Norovirus and therefore any other competitor or team member was diagnosed as having the same. This would be the same procedure for a ward or care home outbreak.
“His [Isaac Makwala’s] condition didn’t start at the medical room (7 Aug Monday),” Sedimo said. “It started before lunch yesterday (Sunday); it’s just that when he arrived at the medical room, medical experts made their own pronouncements.”
In fact the IAAF said the decision to withdraw him from the 200m heats last night (7 Aug Monday) and the 400m final today (8 Aug Tuesday) was made on the basis of a medical examination conducted in the warm-up medical centre by a qualified doctor on Monday (7 Aug) and recorded in the electronic medical record system of the championships. A copy of this medical record was given to a member of the Botswanan team’s medical staff following the examination.
The letter sent by the IAAF to all the teams is very clear and states “recommendations from Public Health England say the affected person must remain isolated for 48 hours after the last episode of vomiting or diarrhoea and therefore, the person will need to take their meals in their room.”
To answer Paula Radcliffe’s question about testing, no, blood cannot be tested. However, stool can be tested by PCR within a few hours BUT in this situation a negative test does not mean the athlete does not have Norovirus. All tests have false positives and false negatives as well as a minimum limit of detection. In an outbreak when someone has symptoms and a negative test the test is considered a false negative and the person still quarantined. In the rare situation when the person might genuinely not have Norovirus but are symptomatic (vomiting and diarrhoea) they are still likely to have another infectious cause which is contagious.
Are we too strict in the UK?
It has been mentioned that PHE have over reacted and been party poopers (no pun intended!). The British former 400m runner Dai Greene tweeted "I was really ill in the build-up [to the 2010 Commonwealth Games] in Delhi as were so many others. But nobody stopped us racing or tested us." Why do we test!? Should we care!!??
The assertion that, “if the situation arose again it would be dealt with very differently” concerns me greatly as I believe this is advocating outbreak management by social media. We need to resist the misinformation and base policy on sound judgement. Clearly it is very disappointing for athletes to miss out when they have trained so hard but think of the headlines if the 400m final only had 2 competitors competing as all the other athletes were sick having been knowingly exposed to a contagious virus in the semi-finals!? It has to be up to the integrity of the individual athlete to ensure they keep themselves and other competitors safe. Paula Radcliffe has rightly raised the issue that “if an athlete has the same symptoms later this week they may well keep it quiet." This may be true but it is not a responsible way to behave.
So in the end, Isaac Makwala’s quarantine period ended at 2pm 9 Aug but unfortunately by this time his race had already been won the evening before by Wayde Van Niekerk from South Africa. In my opinion PHE were 100% correct in their advice and action during the World Athletic Championships. This was a clear case of when having “the runs” at an athletics event was not a good thing!
Note: the hotel in this case has stated that investigations have confirmed that the hotel was not the source of the illness; they have stated “we have followed strict hygiene protocol, ensuring that those affected are not in contact with other guests and all public areas have been thoroughly sanitised.”
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