[Health] The Infectious Diseases Thread

[Isgrimnur]

Florida

Florida confirmed Monday 10 more homegrown cases of Zika in people infected by local mosquitoes, leading federal health officials to advise women who are pregnant to avoid the area just north of downtown Miami where Zika is spreading.

Women have visited the Wynwood neighborhood in Miamia since June 15 should avoid getting pregnant for at least eight weeks, according to the Centers for Disease Control and Prevention. Zika appears to have begun spreading among mosquitoes in this area around June 15.

This is the first time in recent memory that the Centers for Disease Control and Prevention has warned people to avoid a community in the continental U.S. because of an outbreak, said Thomas Frieden, CDC director.

At Florida's request, the CDC is sending an emergency response team to the state to help control the outbreak. Two CDC staff are already working in Florida, with six more planning to join them.

The new Zika cases in Miami bring the number of Zika infections spread by local mosquitoes — as opposed to foreign travel — to 14.
...
"We don't have ideal ways to control the mosquitoes that control Zika," Frieden said. "In Miami, aggressive mosquito control measures don't seem to be working as well as we would have liked."
...
The local cases in Miami are a major development, because — with the exception of one Zika case related to a lab accident — all of the Zika infections in the U.S. until now have been been diagnosed in people who traveled abroad or in people who had sex with a traveler. Although Zika is largely spread by mosquitoes, both men and women can transmit the virus sexually.

[Isgrimnur]

That lab accident:

A female researcher was accidentally infected with the Zika virus during a laboratory experiment at the University of Pittsburgh, marking the first reported case of someone getting the virus through a needle stick, university officials said today.

The researcher accidentally pricked herself with a needle on May 23 and developed symptoms on June 1, according to a university statement. She returned to work five days later when she no longer had a fever, according to the statement.

“We want to remind residents that, despite this rare incident, there is still no current risk of contracting Zika from mosquitoes in Allegheny County,” Dr. Karen Hacker, director of the Allegheny County Health Department, said in a separate statement today.

Even so, the researcher plans to wear insect repellent, long sleeves and pants for three weeks, according to the University of Pittsburgh.
...
Hacker confirmed that the laboratory researcher had not traveled to an endemic area, nor had she acquired the virus through sexual contact. The three other known Zika cases in Allegheny County were men who had contracted the virus abroad, she said.

I'd make a crack about her needing remedial training, but seeing as there's over 1k a day in the U.S....

The Centers for Disease Control and Prevention (CDC) estimates that about 385,000 sharps-related injuries occur annually among health care workers in hospitals.

[Smoove_B]

Yup. That's why I provided blood-borne pathogen training at one point in my life. Nurses are definitely at the greatest risk, but police officers, janitors and waste haulers can be exposed too.

[Combustible Lemur]

#smoovesignal!

Keri and I were planning on starting a family this year. Is Zika really breaking out? We do live in Houston..... so mosquito central. News says yes. But news also said ebola was going to kill everyone.

[Smoove_B]

I'd always defer to the CDC and thankfully they have an excellent page devoted to answering these types of questions:

Are you pregnant? Here’s what you can do to protect yourself if you don’t currently live in an area with Zika.
1. Avoid travel to an area with Zika.

Until we know more, CDC recommends special precautions for pregnant women. Women who are pregnant should not travel to any area where Zika virus is spreading.
If you must travel to one of these areas, talk to your doctor or other healthcare provider first and strictly follow steps to prevent mosquito bites during your trip.

2. Take steps to prevent mosquito bites.

Wear long-sleeved shirts and long pants.
Stay in places with air conditioning and window and door screens to keep mosquitoes outside.
Use Environmental Protection Agency (EPA)-registered insect repellents. When used as directed, these insect repellents are proven safe and effective even for pregnant and breastfeeding women.
Remove or stay away from mosquito breeding sites, like containers with standing water.

Essentially the one neighborhood in Miami is ground zero right now as most of our attention was collectively focused on people traveling to areas where Zika was likely present. If it's truly now something people can get in the United States, it's only a matter of time before it's spreading through the deep South (at least based on what I've read). You do have people in your area that are carrying the virus but they are all travel related cases. I wouldn't be surprised to see other locally-acquired cases happening in the American South this summer but it might not be something we see until next year. Like West Nile Virus we're collectively experiencing out outbreak in real time that's never been experienced before.

Regardless, the Houston page is also linking to the CDC for more information and guidance regarding pregnancy and Zika.

So..is it breaking out? Technically yes. Is it in your area? Unknown but I have to trust that local mosquito control specialists are monitoring. Will it be? Magic 8-Ball suggests it is likely (eventually) if I'm to believe the mosquito experts - especially in the gulf coast area. I have to admit, I'm at a loss here as for all the pregnancy related health information I have, Zika is not part of my repertoire (yet). It really is just so damn new, but any type of mosquito prevention strategies would be a wise bet regardless.

Also, get yourselves to a doctor for some pre-conception care. Above and beyond Zika, you want to do everything you can to promote a healthy outcome for everyone.

[Combustible Lemur]

Gracias. That pretty much what we had read up to this point as well. But hearing it with a personal touch is "reassuring/terrifying"?.

[Kraken]

OK then, an indelicate follow-up: Can they detect pinhead fetuses while it's still legal to abort them? I mean, nobody wants to be confronted with that decision, but is carrying one to term even a decision?

[Zarathud]

This is going to be the major battle, particularly in states run by pinhead Republicans.

[Pyperkub]

This is going to be the major battle, particularly in states run by pinhead Republicans.

Just think of it as enabling little-head mode...

[ImLawBoy]

It's probably worth noting here that terms like "pinhead" or "little head mode" are incredibly insulting and derogatory. It's also worth noting that microcephaly is not a death sentence, and people with microcephaly, while they will have challenges, can still lead fulfilling lives, love, and be loved.

[Jeff V]

It's probably worth noting here that terms like "pinhead" or "little head mode" are incredibly insulting and derogatory. It's also worth noting that microcephaly is not a death sentence, and people with microcephaly, while they will have challenges, can still lead fulfilling lives, love, and be loved.

Not if they are Republican.

[Ralph-Wiggum]

Does the CDC have any idea how local mosquitoes in Miami started carrying Zika? I.E. did mosquitoes carrying the virus get transported to Miami or did mosquitoes in Miami bite someone infected from travel with Zika?

[Smoove_B]

Does the CDC have any idea how local mosquitoes in Miami started carrying Zika? I.E. did mosquitoes carrying the virus get transported to Miami or did mosquitoes in Miami bite someone infected from travel with Zika?

Not that I've seen, no. Based on what happened with West Nile, I'd imagine the second scenario is most likely but either one could be the cause. Similarly, there could be other reservoirs for Zika that we're not aware of yet. Again, in the same way that it was spread via migrating birds to the American south, midwest and west, Zika could be moving through another species as well. If mosquitoes are feeding on those animals it's going to delay our understanding of the etiology until we figure out all the various parts. I get updates every few days from the state of NJ and 95% of the information is focused on education and awareness, specifically targeted at pregnant women and people planning to travel to areas we already know are problematic.

[Ralph-Wiggum]

Do we know how genetically variable the Zika virus is (e.g. does the Zika in PR differ genetically from the Zika in Brazil)? If it is variable, that may be one way to at least narrow down how it is spreading.

[Smoove_B]

Gracias. That pretty much what we had read up to this point as well. But hearing it with a personal touch is "reassuring/terrifying"?.

I really think there's been a concerted effort to try and stay "on message" for these types of outbreaks. Communication was a mess during the Anthrax attacks in 2001 and I was also rather surprised at how disorganized Ebola was. However, we do have a pretty good (national) system in place for mosquito-borne diseases so this is really using a system that already exists to deliver a different message - assuming your state and locals are also prepared.

The biggest problem will be for states that cut their mosquito control funding after WNV died down and/or states that haven't been adequately funding state or local mosquito control to begin with. My own experience here in NJ is that after WNV hit in 1999, money was flowing like a river and mosquito agencies were hiring people to keep up with demand. Eventually the money dried up and staffing levels went back to what they were prior to WNV. There were a few articles I saw months ago about how the coastal, poorer cities in Texas might end up being "ground zero" for Zika in the United States. It would appear Florida beat you to it, but I don't know the scope (I don't think anyone does) of what's happening in Florida right now to say for sure.

Simple things like air conditioning, window screens and properties free of debris that can hold standing water (tires, buckets, etc...) might make all the difference in the world as to why one community has a Zika problem and another doesn't.

[Smoove_B]

Do we know how genetically variable the Zika virus is (e.g. does the Zika in PR differ genetically from the Zika in Brazil)? If it is variable, that may be one way to at least narrow down how it is spreading.

I don't know if they've drilled down that far into the strains, other than to generally identify where it likely came from and possibly how it's been spreading around the globe:

Our results strengthen previous epidemiologic evidence that the EC Yap strain originated in Southeast Asia [9], [17]. This conclusion is further substantiated by the geographic proximity of Yap Island to known areas of ZIKV transmission (Indonesia and Malaysia). It has been reported that wind-blown mosquitoes can travel distances of several hundred kilometers over the open ocean [25], [26]. However, due to the great distances involved, it seems likely that the virus was introduced as a result of travel or trade activities whereby either a viremic person, enzootic host species, and/or an infected and subsequently infective mosquito (adult or immature) was transported to the island as suggested by Duffey et al. [9]. This hypothesis is further supported by the fact that no monkeys were present on Yap Island during the 2007 epidemic [9].

The phylogenetic results indicate that the Cambodian strain diverged from the Malaysian strain in the recent past. Therefore, the most recent common ancestor of the Cambodian strain has been circulating in Southeast Asia since at least the mid-1900's. These data indicate that Cambodian strain was either recently introduced or that it has been circulating in the region and has remained undetected until 2010. Seroprevalence surveys might help to determine when ZIKV was introduced into Cambodia.

There's also the issue as to why certain populations are at increased risk for complications with pregnancy and others seemingly are not.

[Smoove_B]

Does the CDC have any idea how local mosquitoes in Miami started carrying Zika?

Now a how, but maybe a bit of the why:

“There are a lot of coffee shops, and other shops and restaurants outside, and those could provide areas where Aedes aegypti mosquitoes are not only breeding but are feeding upon people,” he told The Daily Beast. “Aedes aegypti mosquitoes like to feed on your lower extremities. They’ll feed on your legs.”

...

In addition to rampant development in Wynwood itself, cranes building new luxury condominium towers on Biscayne Boulevard line the eastern edge of the small area identified by the CDC as a new danger zone for pregnant women and their partners.

“Generally around construction sites, you have catchments of water in any number of things: pails, buckets, trash,” said Conlon. “Anything around a construction site that can hold water is fair game.”

[Defiant]

People are concerned about the Zika Virus:




No word yet about how concerned people are at misuse of bar graphs.

[Kraken]

People are concerned about the Zika Virus:




No word yet about how concerned people are at misuse of bar graphs.

The graph works if you reverse the order of the numerical display. Which raises the question of whether the bars or the numbers are displayed right. Either way, bar graph fail for sure.

[Max Peck]

People are concerned about the Zika Virus:




No word yet about how concerned people are at misuse of bar graphs.

The graph works if you reverse the order of the numerical display. Which raises the question of whether the bars or the numbers are displayed right. Either way, bar graph fail for sure.

No, if you reverse the numbers (which would better match the results for other polling on the question) the height of the bars is still out of whack, with 13 higher than 25 or 28. NBC-2.com appears to be in Florida, so my best guess is that the numbers are correct (if people aren't worried about Zika in Florida, then they aren't worried anywhere) and the bar graph is out to lunch.

[Kraken]

People are concerned about the Zika Virus:




No word yet about how concerned people are at misuse of bar graphs.

The graph works if you reverse the order of the numerical display. Which raises the question of whether the bars or the numbers are displayed right. Either way, bar graph fail for sure.

No, if you reverse the numbers (which would better match the results for other polling on the question) the height of the bars is still out of whack, with 13 higher than 25 or 28. NBC-2.com appears to be in Florida, so my best guess is that the numbers are correct (if people aren't worried about Zika in Florida, then they aren't worried anywhere) and the bar graph is out to lunch.

Oops, yup, my brain screwed up the x-flip. Never mind. (Stupid brain.)

[Blackhawk]

My first thought was that they'd somehow inverted them, but that still puts the 34 between 13 and 25. It is just scrambled.

I'm curious about exactly what they asked for the numbers, though. Am I concerned about the Zika virus?

In general, yes, absolutely. A great deal of suffering amongst my fellow human beings in potentially in the works. That's something to be concerned about.

In respect only to myself? Not even remotely. I'm a decade single, and clipped in any case, so I won't be producing offspring or spreading it. None of my friends or family are likely to produce offspring anytime soon (family is all too old, friends are mostly gay.) The worst I am likely to suffer would be a cold.

In other words, how someone might answer on that question would depend on either how it was asked, or how it was interpreted. Without knowing that, you really can't give it any meaning.

[Paingod]

It's also worth noting that microcephaly is not a death sentence, and people with microcephaly, while they will have challenges, can still lead fulfilling lives, love, and be loved.

I believe in being pro-choice, and that if someone can terminate a pregnancy because it is unwanted, they should also have the option to terminate if the pregnancy was wanted but the resulting offspring is going to require a degree of abnormal effort to be raised. To each their own, really. I admire people who raise children with disabilities and never cease to be amazed by their strength - I just don't know if I could do it, and I don't expect anyone else to.

Back to Kraken's question on detection and abortion...

First, when can we detect microencephaly?

Genetic testing plus amniocentesis — a sampling of the amniotic fluid — may reveal a fetal infection with Zika virus as early as 15 weeks of gestation, according to the American College of Obstetricians and Gynecologists, but earlier time frames may endanger the baby.

The earliest that microcephaly can be detected, regardless of the cause, is late in the second trimester of gestation (18 to 20 weeks), according to the CDC.

Next, can we abort in the second trimester because of microencephaly?

If a pregnant person were to test positive for Zika, that would essentially put her in a waiting game with her pregnancy, Dr. Chastine said. If she wanted to ensure she gave birth to a baby without microcephaly, she would need to wait until sometime in the late second trimester to see if the virus may have impacted the development of the fetus, knowing she would need massive financial resources to travel to a state with later abortion limits. Her other choice would be to abort earlier, even if that potentially means terminating what might have been a healthy pregnancy, and trying again. The decision is likely to be an economic one, and it will be those of lesser means who will be the most likely to face terminating a pregnancy that may have been a healthy one.

Seems like it'll depend on your economic status and ability to find a place where later-term abortions are allowed. If you're poor and worried, you may have to terminate a healthy fetus to be "safe". If you're wealthy and worried, you can hang tight to see what the test results are and then make a choice based on the facts.

[Kraken]

Thanks for running down that answer. It's more complicated than the simple yes/no that I expected.

[Isgrimnur]

Miami Beach

Mosquitoes have begun spreading the Zika virus in a second part of Miami — the popular tourist destination of Miami Beach — Florida officials announced Friday.

As a result, the federal Centers for Disease Control and Prevention expanded its advice to travelers, advising pregnant women to avoid the parts of Miami Beach where the virus is spreading. In addition, women and men who have traveled to the area should wait at least eight weeks to try to get pregnant even if they didn't catch Zika during their visit.
...
Five Zika cases have been linked to the new outbreak in Miami Beach, involving three men and two women from Miami, New York, Texas and Taiwan, officials said. That brings the total number of Zika cases that have been spread by mosquitoes in Florida to 36.
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The tourism industry in Florida is particularly concerned with the spread of Zika and the impact it may have on businesses. On Thursday, Scott announced measures designed to limit Zika, including offering mosquito spraying free of charge to businesses in Miami-Dade County.
...
In response to the Miami Beach outbreak, Scott said he had requested an additional 5,000 Zika tests, additional lab personnel to expedite testing and 10,000 more Zika prevention kits for pregnant women.

[Isgrimnur]

WaPo

By the time the man arrived at the lung disease clinic in Manchester, England, it was almost too late. It was April 2014 and the 61-year-old had spent the past seven years finding it harder and harder to breathe. Once able to run 10 kilometers, he could now barely walk 20 meters. His lungs were operating at a third their proper capacity. Doctors were stumped.

Five years earlier, the man had been diagnosed with a serious inflammation of the lungs, known as hypersensitivity pneumonitis, or HP.

HP has a variety of other names, each one of which offered a possible solution to the medical mystery: farmer’s lung, hot tub lung, humidifier lung and, perhaps oddest of all, pigeon fancier’s lung.

When doctors tried to pin down the cause of the man’s malady, however, it eluded them. He didn’t smoke. His home wasn’t hiding any mold. He didn’t have connective tissue disease, which can cause breathing problems. And he did not fancy pigeons.

The only clue physicians at the University Hospital of South Manchester could see was that the man’s symptoms had rapidly improved when he moved to Australia for three months, only for his breathing to deteriorate once again as soon as he returned to the United Kingdom.
...
Despite their efforts, the man died on Oct. 10, 2014. An autopsy didn’t explain much. It merely showed that his lungs were badly scarred, which was attributed to the years of inexplicable HP. The medical examiner chalked the cause of death up to “acute exacerbation of ILD,” or interstitial lung disease, a broad category.

Now, however, nearly two years after the man’s death, doctors say they have solved the medical mystery. In a report published Monday in the medical journal Thorax, a team of five UHSM researchers coined a new term for the man’s condition.

“Bagpipe lung.”
...
According to the paper, when doctors initially tried diagnosing the man’s illness, they overlooked his daily hobby: playing the bagpipes. Tests conducted on the man’s bagpipes found a slew of fungi and yeast living inside the musical instrument.
...
Unknown to the piper, who was not named in the study, every time he played his instrument, he was inhaling a mixture of mold that caused his illness. His brief recovery in Australia had coincided with him leaving his bagpipes home in the U.K.
...
The study noted similar illnesses befalling saxophone and trombone players, although they were fortunate enough for their instruments to be identified as the cause before it was too late.

[Isgrimnur]

Zika

All blood donated in the U.S. should be screened for Zika to prevent the virus from spreading through transfusions, the Food and Drug Administration said Friday.

The new guidance should be implemented “immediately” in states and territories where the virus is already being spread by mosquitoes, and it should be phased in over the next four to 12 weeks in the rest of the country.
...
Florida is the only U.S. state with Zika infections that can’t be linked to travel. As of Wednesday, 29 people there have been diagnosed with laboratory-confirmed infections, the CDC says.
...
Donor blood can be another important source of Zika transmission. During a Zika outbreak in French Polynesia in 2013 and 2014, nearly 3% of blood samples from people with no sign of infection were found to contain the virus, which could have been spread to others through routine infusions.

And in Puerto Rico, where screening has been recommended since February, nearly 1% of blood samples from donors with no symptoms of Zika turned up positive for the virus, according to the FDA.

Screening potential donors before they give blood is unreliable, since four out of five infected people never develop any outward sign of infection. Among those who do, most have vague symptoms like fever, headaches or joint or muscle pain.

To get around this problem, the FDA’s new guidance calls for testing all donated blood using a so-called nucleic acid test. These tests search for specific genetic sequences in certain viruses, such as HIV or hepatitis. Versions that look for Zika are still undergoing final FDA review.

[Smoove_B]

Zika

All blood donated in the U.S. should be screened for Zika to prevent the virus from spreading through transfusions, the Food and Drug Administration said Friday.

It's also a really good way to see where it might be spreading that we're not aware of. Sort of how we use nanobot trackers in Flu vaccinations.

[Isgrimnur]

President Obama

[Smoove_B]

For those eagerly awaiting an update on semen (emphasis added):

Initial data from a Liberian public health program show about 9 percent (38) of 429 male Ebola survivors had fragments of Ebola virus in their semen. Of those, 63 percent had semen samples that tested positive for Ebola fragments a year after recovering from disease and, in one man’s case, at least 565 days after he recovered from illness. Men older than 40 were more likely than younger men to have a semen sample test positive.

[stessier]

Are fragments enough to cause an infection?

[Smoove_B]

Are fragments enough to cause an infection?

I don't believe so, no. But it suggests that the virus is persisting in some form in the human body for much longer than was originally thought - and long after a person returns to normal health. This type of information will likely be used to come up with a better understanding for how long it's potentially infectious after a person recovers. It could also be used to trace outbreaks or figure out how they are being spread.

EDIT: This Reuters article is a bit less technical:

Semen samples in the study were tested for genetic fragments known as the viral RNA, but the tests could not tell if the virus was capable of spreading disease.

Sexual contact with an Ebola survivor in March 2015 resulted in the infection and eventual death of a woman from Monrovia, even after Liberia had been declared free of Ebola. Tests of the man's semen showed the presence of Ebola virus 199 days after he first became ill.

[Ralph-Wiggum]

Did you see this recent news, Smoove? Pretty wacky.

That’s the case for the Guaico Culex virus (GCXV) - a new type of 'multicomponent' virus that’s been identified for the first time in living mosquitos.

For some reason, the genetic material of Guaico Culex has been split up into five independent packages, and in order to be infected by it, you need to be exposed to at least four different types.

"The fifth ball seems to be optional," says one of the team, Jason Ladner, adding that perhaps getting the fifth part determines how strong the effect will be on the host.

Until now, multicomponent viruses were thought to only infect plants and fungi, because their mode of transmission seems so incredibly inefficient. But now that the Guaico Culex virus has been found in several Culex mosquitos in the Guaico region of Trinidad, the question is, how many other animals could be affected by it?

[Smoove_B]

Whoa, no I had not. That's insane.

[Isgrimnur]

The Stuxnet of ... viruses ...

[stessier]

Frozen strawberries from Egypt are spreading Hep A in 6 states (so far).

An outbreak of hepatitis A caused by imported frozen strawberries from Egypt has sickened 55 people in six states, the US Centers for Disease Control and Prevention said Wednesday. Health authorities confirmed 44 total infections in Virginia, where the outbreak first appeared, and additional infections in Maryland (4), West Virginia (4), North Carolina (1), Oregon (1) and Wisconsin (1).

Hepatitis A is a viral liver infection that is highly contagious but does not result in chronic infection.

***

he Virginia Department of Health originally connected the infection to smoothies, which contained the imported berries, served at Tropical Smoothie Café restaurants.

Almost all those who became sick purchased smoothies at cafés in a limited region including Virginia and neighboring states, reported the CDC. The one ill person in Oregon had traveled to Virginia.

[Freyland]

The Stuxnet of ... viruses ...

Or a viral Power Ball lottery.

[Isgrimnur]

The death of antibacterial soap

The U.S. Food and Drug Administration today issued a final rule establishing that over-the-counter (OTC) consumer antiseptic wash products containing certain active ingredients can no longer be marketed. Companies will no longer be able to market antibacterial washes with these ingredients because manufacturers did not demonstrate that the ingredients are both safe for long-term daily use and more effective than plain soap and water in preventing illness and the spread of certain infections. Some manufacturers have already started removing these ingredients from their products.

This final rule applies to consumer antiseptic wash products containing one or more of 19 specific active ingredients, including the most commonly used ingredients – triclosan and triclocarban. These products are intended for use with water, and are rinsed off after use. This rule does not affect consumer hand “sanitizers” or wipes, or antibacterial products used in health care settings.
...
The agency issued a proposed rule in 2013 after some data suggested that long-term exposure to certain active ingredients used in antibacterial products — for example, triclosan (liquid soaps) and triclocarban (bar soaps) — could pose health risks, such as bacterial resistance or hormonal effects. Under the proposed rule, manufacturers were required to provide the agency with additional data on the safety and effectiveness of certain ingredients used in over-the-counter consumer antibacterial washes if they wanted to continue marketing antibacterial products containing those ingredients. This included data from clinical studies demonstrating that these products were superior to non-antibacterial washes in preventing human illness or reducing infection.

Antibacterial hand and body wash manufacturers did not provide the necessary data to establish safety and effectiveness for the 19 active ingredients addressed in this final rulemaking. For these ingredients, either no additional data were submitted or the data and information that were submitted were not sufficient for the agency to find that these ingredients are Generally Recognized as Safe and Effective (GRAS/GRAE). In response to comments submitted by industry, the FDA has deferred rulemaking for one year on three additional ingredients used in consumer wash products – benzalkonium chloride, benzethonium chloride and chloroxylenol (PCMX) – to allow for the development and submission of new safety and effectiveness data for these ingredients. Consumer antibacterial washes containing these specific ingredients may be marketed during this time while data are being collected.
...
Since the FDA’s proposed rulemaking in 2013, manufacturers already started phasing out the use of certain active ingredients in antibacterial washes, including triclosan and triclocarban. Manufacturers will have one year to comply with the rulemaking by removing products from the market or reformulating (removing antibacterial active ingredients) these products.

[Lorini]

I'm on a cruise ship where they destroyed their library because of what they are calling a 'small' norovirus outbreak on the ship. Only one more day before I get out of here. There's Purell everywhere, you can't enter the dining areas without using it but I'm washing my hands with soap and water as much as possible.

[Smoove_B]

While that's a good plan, Norovirus is interesting (horrifying? disgusting?) in that it can be spread via the aerosol route as well. If people around you are throwing up, run the other way.