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Norovirus gastroenteritis outbreaks in military units: a systematic review
  1. Luis Queiros-Reis1,
  2. A Lopes-João2,
  3. J R Mesquita3,4,
  4. C Penha-Gonçalves2,5 and
  5. M S J Nascimento1,4
  1. 1 Laboratório de Microbiologia, Departamento de Ciências Biológicas, Faculdade de Farmácia da Universidade do Porto (FFUP), Porto, Portugal
  2. 2 Laboratório de Bromatologia e Defesa Biológica do Exército (LBDB), Lisboa, Portugal
  3. 3 Departamento de Ciências Veterinárias, Instituto de Ciências Biomédicas Abel Salazar (ICBAS), Universidade do Porto, Porto, Portugal
  4. 4 Epidemiology Research Unit (EPIUnit), Instituto de Saúde Pública da Universidade do Porto, Porto, Portugal
  5. 5 Fundacao Calouste Gulbenkian, Lisboa, Portugal
  1. Correspondence to Professor J R Mesquita, Instituto de Ciências Biomédicas Abel Salazar. Rua de Jorge Viterbo Ferreira, 228, Porto 4050-313, Portugal; jrmesquita{at}


Introduction Norovirus gastroenteritis is one of the most frequent causes of personnel unavailability in military units, being associated with significant morbidity and degradation of their operational effectiveness. The disease is usually mild but can be severe and life-threatening in young and healthy soldiers, who are prone to dehydration due to intensive daily activity. Despite its impact, the full extent of the norovirus gastroenteritis burden in military forces remains unclear. This systematic review aims to evaluate the impact and ascertain clinical and epidemiological features of norovirus outbreaks that have occurred in the military forces.

Methods The systematic review followed the Preferred Reporting Items for Systemic Reviews and Meta-Analysis (PRISMA) guidelines and used three databases: PubMed, Scopus, and LILACs. Papers published up to 1 September 2019 were included without restrictions if they reported one or more outbreaks in the military forces on active duty, either on national territories or deployed overseas.

Results A total of 343 papers were retrieved from the literature search. After inclusion/exclusion criteria a total of 39 eligible papers were considered. From 1988 (first reported outbreak in the military) to 2018 more than 101 norovirus outbreaks have been reported in the military, accounting for at least 24 332 cases. Secondary transmission was emphasised as the main route of norovirus transmission in the military forces, with eating outside the military setting an important route for the primary cases.

Conclusions The present review highlights that norovirus gastroenteritis has been a burden to military troops both in combat and on peacekeeping operations. Norovirus disease has been shown to exact a substantial toll on mission readiness and operational effectiveness. It is noteworthy that the impact of norovirus outbreaks among military units is underestimated because the literature review retrieved information from the armed forces from only nine countries.

  • virology
  • infectious diseases
  • epidemiology

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  • Contributors All authors have significantly contributed to planning, conducting and writing of the work.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement All data relevant to the study are included in the article or uploaded as supplementary information.