Objective: To determine the frequency and clinical features of Rota virus diarrhea in children presenting in a tertiary care hospital.
Study Design: A cross-sectional, observational study.
Place and Duration of Study: National Institute of Child Health, Karachi, from January to June 2007.
Methodology: A total of three hundred children of either gender aged 1 month to 5 years, who presented with diarrhea of \u3c 7 days as a primary illness were enrolled. Children with bloody diarrhea or nosocomial gastroenteritis acquired duringhospitalization for other disease were not included. Detection of Rota virus in stool was done by enzyme linked immunoassay.
Results: Out of 300 children, 188 (63%) tested positive and 112 (37%) tested negative for Rota virus. Positive Rota virus cases in 7 – 12 months of age was (n = 34, 18.08%). Overall, 151 (80.3%) children with Rota virus were less than 3 years old. 182 (60.7%) had fever, 118 (39.3%) had vomiting and 156 (82.9%) children had both fever and vomiting.
Conclusion: This study shows that Rota virus is a common organism causing diarrhea in children less than 3 years of age. There is a need to incorporate Rota virus vaccine in the national EPI program to decrease the disease burden as highlighted in this study

Habib, Muhammad Irfan

Kazi, Sayyeda Ghazala

Khan, Khalid Mehmood Ahmed

Zia, Nukhba

eCommons@AKU

eCommons@AKUDepartment of Emergency Medicine Medical College, PakistanFebruary 2014Rota virus diarrhea in hospitalized childrenMuhammad Irfan HabibNational Institute of Child HealthSayyeda Ghazala KaziAga Khan University, ghazala.kazi@aku.eduKhalid Mehmood Ahmed KhanNational Institute of Child HealthNukhba ZiaAga Khan University, nukhba.zia@aku.eduFollow this and additional works at: http://ecommons.aku.edu/pakistan_fhs_mc_emerg_medPart of the Digestive System Diseases Commons, Emergency Medicine Commons, and thePediatrics CommonsRecommended CitationHabib, M. I., Kazi, S. G., Khan, K. A., Zia, N. (2014). Rota virus diarrhea in hospitalized children. Journal of the College of Physicians andSurgeons Pakistan, 24(2), 114-117.Available at: http://ecommons.aku.edu/pakistan_fhs_mc_emerg_med/40114 Journal of the College of Physicians and Surgeons Pakistan 2014, Vol. 24 (2): 114-117INTRODUCTIONRota virus is the most important etiological agent ofacquired diarrhea in infants and young children and is avaccine preventable disease, is considered to be mostcommon pathogen responsible for causing severediarrhea and dehydration in children less than 5 years ofage. According to WHO estimates in 2004 over fivemillion children aged < 5 years died from Rota virusinfection. About half of these deaths occurred in India,Nigeria, the Democratic Republic of the Congo, Ethiopia,China and Pakistan.1 Recent estimates show thatabout 65,000 children die each year in the EasternMediterranean Region (EMR) which also includesPakistan. Although the mortality is higher in the low-income countries of the region, the burden of severeRota virus disease among less than 5 years old childrenrequiring hospitalization and clinical visits is equallyshared by all the countries of the region.2Rota virus infection results in a large number ofhospitalizations, costs and mortalities.3,4 The global andnational estimates from WHO state that the proportionsof hospitalizations due to Rota virus diarrhea rangedfrom 16% to 66% with a median proportion of 38% (inter-quartile range, 26% – 43%).5 Pakistan has a populationof more than 17 million, of which 43% are children. WHOestimates show that the mortality due to Rota virus inchildren less than 5 years is 95/100,000 in under fivepopulations.1In 1998, the US Food and Drug Administration approveda live virus vaccine (Rota Shield) for use in children butit was linked to an increased risk for intussusception.Because the immune response to the infection reducesthe occurrence and severity of subsequent infections,diarrhea due to Rota virus may be controlled throughvaccination.6 Rota virus illness typically begins with thesudden onset of diarrhea and vomiting. The diarrhea isusually watery and rarely has blood in it. Fever may bepresent in most of the patients. The purpose of this study was to determine thefrequency of Rota virus in children hospitalized withdiarrhea lasting for less than 7 days.METHODOLOGYIt was a cross-sectional, observational study conductedat Diarrhea Treatment Unit, National Institute of ChildHealth, Karachi, from January to June 2007. Threehundred patients of either sex from 1 month to 5 yearswith symptoms of acute gastroenteritis of less than 7days were included in the study. Children with bloodydiarrhea and those who acquired gastroenteritis duringhospitalization for treatment of other disease wereexcluded. Written consent was taken from parents/caregiver after explaining the purpose of study. Nocharges were demanded from the caregiver for theoverall treatment. As it was not an interventional studyORIGINAL ARTICLERota virus Diarrhea in Hospitalized ChildrenMuhammad Irfan Habib1, Sayyeda Ghazala Kazi2, Khalid Mehmood Ahmed Khan1 and Nukhba Zia2ABSTRACTObjective: To determine the frequency and clinical features of Rota virus diarrhea in children presenting in a tertiarycare hospital.Study Design: A cross-sectional, observational study.Place and Duration of Study: National Institute of Child Health, Karachi, from January to June 2007.Methodology: A total of three hundred children of either gender aged 1 month to 5 years, who presented with diarrhea of< 7 days as a primary illness were enrolled. Children with bloody diarrhea or nosocomial gastroenteritis acquired duringhospitalization for other disease were not included. Detection of Rota virus in stool was done by enzyme linkedimmunoassay.Results: Out of 300 children, 188 (63%) tested positive and 112 (37%) tested negative for Rota virus. Positive Rota viruscases in 7 – 12 months of age was (n = 34, 18.08%). Overall, 151 (80.3%) children with Rota virus were less than 3 yearsold. 182 (60.7%) had fever, 118 (39.3%) had vomiting and 156 (82.9%) children had both fever and vomiting.Conclusion: This study shows that Rota virus is a common organism causing diarrhea in children less than 3 years ofage. There is a need to incorporate Rota virus vaccine in the national EPI program to decrease the disease burden ashighlighted in this study.Key Words: Diarrhea.   Dehydration.   Rota virus.1 Department of Paediatrics, National Institute of Child Health,Karachi.2 Department of Emergency Medicine, The Aga Khan University,Karachi.Correspondence: Dr. Muhammad Irfan Habib, B-82, Block-W,North Nazimabad, Karachi.E-mail: irfan.habib@childlifefoundation.orgReceived: October 29, 2010;   Accepted: October 14, 2013.approval from ethical committee of the institute was notsought.Stool samples were collected as soon as possible within24 – 48 hours to avoid nosocomial infection. Stoolcontainers were labeled with the unique patientidentifier. One spoon full of diarrhea stool recentlyvoided in diaper was transferred into the labeledcontainer with the spoon provided in container. Stoolspecimens with the request and feedback form weresent to hospital laboratory. Short-term storage was doneat 2 – 80°C in the laboratory for detection of Rota virusby EIA (enzyme linked immunoassay) within 20 minutesof collection. Reagent used was DAKO IDEIA present inRota virus EIA detection kit that contains a positivecontrol and a negative control which were performedwith each assay to ensure that kit reagents were used;the positive control was deep blue and easilydistinguished from the negative control. The negativecontrol was colourless or faint blue.For the purpose of the study, diarrhea was defined asthe acute occurrence (symptoms of onset less than7 days) of at least 3 looser than normal or watery stoolsin a 24 hours period; vomiting was defined as two ormore episodes of vomiting un-explained by otherreasons. Dehydration was categorized into nodehydration (not enough signs to classify as some orsevere dehydration), some dehydration (two or more ofthe following signs: (a) restless, irritable, (b) sunkeneyes, (c) drinks eagerly, thirsty and (d) skin pinch goesback slowly) and severe dehydration (two or more of thefollowing signs: a. lethargic or unconscious, (b) sunkeneyes, (c) not able to drink or drink poorly and (d) skinpinch goes back very slowly).Data was entered and analyzed in Statistical Packagefor Social Sciences (SPSS) version 10. Frequencies andpercentages were calculated for all qualitative/categorical variables including gender, age groups,symptoms, number of vomiting, duration of symptomsand result of Rota virus detection (positive or negative).Mean and standard deviation was computed for age.Chi-square test was used to see the association of agegroups and gender with Rota virus (positive or negative),at 5% level of significance.RESULTSA total of 300 children admitted with complaint of acutewatery diarrhea were evaluated. Out of 300 children,180 (60%) were males and 120 (40%) females (M: Fratio = 1.5: 1). The mean age of children was 20.56(SD ± 15.14) months and age range was 1 - 60 months.The highest frequency of symptoms was observed in 74(24.6%) children who were between 7 - 12 months ofage, 51 (17%) children were between 1 - 6 months. Atotal of 177 (59%) children had symptoms for 1 - 3 days,and 123 (41%) children had symptoms from 4 - 6 days.Fever was seen in 182 (60.7%) children and vomiting in118 (39.3%). Out of 118 children who presented withvomiting, 70 (59.3%) had 5 - 7 episodes of vomiting, 37(31.3%) children had 2 - 4 episodes while 11 (9.3%)children had 8 - 9 episodes of vomiting. A total of 195(65%) children had diarrhea for 1 - 3 days and 104(34.7%) children had diarrhea for 4 - 6 days and onlyone child continued to have diarrhea for 7 - 9 days.About 8 - 11 episodes of diarrhea per day were seen in181 (60.3%) children, 12 - 15 episodes per day in 68(22.7%) children and 4 - 7 episodes per day in 51 (17%)children.Rota virus was positive in 188 (63%) children that wassignificantly high proportion as compared with 112 (37%)children who were found to be negative for Rota virus(p < 0.001). The highest frequency of Rota virus positivecases (34, 18.08%) was observed in children between7 - 12 months of age. The frequency of Rota virusdisease in children of other age groups was found to be15.4% (n=29) between ages of 1 - 6 months, 10.1%(n=19) cases each between ages of 13 - 18 months and19 - 24 months, 15.9% (n=30%) cases between ages of25 -30 months and 10.6% (n=20) cases between ages of31 - 36 months. A total of 151 (80.31%) children withRota virus were under 3 years of age. A significantassociation was seen between age and Rota virus(p < 0.001). Rota virus was detected more frequently inRota virus diarrhea in hospitalized childrenTable I: Distribution of Rota virus according to age groups (n=300).Age group Rota virus Number of(in months) Negative Positive patients01-06 months 22 29 5107-12 months 40 34 7413-18 months 23 19 4219-24 months 13 19 3225-30 months 7 30 3731-36 months 3 20 2337-42 months 1 7 843-48 months 3 16 1949-54 months 0 4 455-60 months 0 10 10Total 112 188 300Figure 1: Age distribution (n = 300). Mean ± SD = 20.56 ± 15.14 months,range = 1 - 60 months.Journal of the College of Physicians and Surgeons Pakistan 2014, Vol. 24 (2): 114-117 115males 116 (61.7%) than in females 72 (38.3%) althoughassociation between gender and Rota virus was notsignificant (p = 0.436).Significant association was found between clinicalfeatures of diarrhea and Rota virus (p < 0.001). Rotavirus was detected more frequently in childrenpresenting with fever ( n = 105) 57.7% out of 182 febrilecases.DISCUSSIONRota viruses are the main pathogens responsible fordiarrheal disease worldwide especially in developingcountries. They result in a large number ofhospitalizations, costs and mortalities. Each year, Rotaviruses cause approximately 111 million episodes ofgastroenteritis in children, which result in 25 million visitsto clinic, 2 million hospitalizations and 3,52,000 to5,92,000 deaths. Virtually, all children become infectedwith Rota virus in the first 3 - 5 years of life, but severediarrhea and dehydration occur primarily among childrenaged 3-35 months. On a worldwide basis, nearly everychild experiences Rota virus gastroenteritis by 5 yearsof age.7A study conducted in Karachi showed Rota virusincidence to be 12.3% in 1990 and 24.4% in 1991.8Children between the age group of 6 - 24 months weremore commonly affected by Rota virus infection. A studyin Washington DC found that most children havedeveloped Rota virus antibodies by age of 2 years,which helps to explain the observed decreasedincidence in later childhood.9Rota virus has an incubation period of 2 - 3 days. Illnesstypically begins with the sudden onset of diarrhea andvomiting. Fluid loss from diarrhea and vomiting aresometimes severe enough to cause dehydration. Feveris present in most patients. There is no significantdifference in clinical presentations of patients with Rotavirus and without Rota virus diarrhea.Dual or mixed infection with human Rota virus and otherenteropathogens, namely E-coli, Giardia lamblia andEntamoeba histolytica were found in 15% of children ina study done in South Africa.10 Such mixed infectionstend to prolong the duration of diarrhea.11 Since bacterio-logical studies were not performed, the bacterial etiologyof diarrheal episodes cannot be commented upon.No test was performed for the identification of specificRota virus serotypes, but group-A Rota viruses are thesingle most important cause of severe acute diarrhea inyoung children throughout the world.12 It is a cause ofsignificant morbidity and mortality among childrenyounger than 5 years of age in India. Of theapproximately 600,000 deaths annually due to Rotavirus worldwide, more than 1, 50,000 occur in India.13,14About 20 – 30% cases of diarrhea are due to Rotaviruses,15,16 making the development and testing of aneffective Rota virus vaccine a necessity. World HealthOrganization recommends that national immunizationprograms of all countries should include Rota virusvaccine. Results from developed countries where thishas been done have shown significant reductions in theburden of severe childhood diarrhea. Clinical trials in thedeveloping world are needed to look at the benefits ofRota virus vaccination in developing countries wherevaccines are likely to have their greatest impact.17An important limitation of this study is that it was done onin-patient children presenting with diarrhea. In order tohave current estimates on Rota virus both communityand hospital based studies are required. Thus, the needfor a national level registry for Rota virus need to bemaintained and the Rota virus vaccine should be addedto the national immunization programme as a primaryprevention against this preventable form of diarrhealdisease.CONCLUSIONThe study has shown that Rota virus is a common causeof diarrhea in children younger than 5 years of age. Rotavirus was found in 63% (188/300) of diarrheal cases.About 80% of the Rota virus infection was found inchildren less than 3 years of age, whereas it was 18% inthe infant age group.Disclosure: It is a dissertation based article.REFERENCES1. WHO. Immunization, vaccines and biologicals Rota virus[Internet]. [updated 2010 Apr 12; cited 2011 January 11];Muhammad Irfan Habib, Sayyeda Ghazala Kazi, Khalid Mehmood Ahmed Khan and Nukhba Zia116 Journal of the College of Physicians and Surgeons Pakistan 2014, Vol. 24 (2): 114-117Table II: Duration of diarrhea in days (n = 300).Duration in days Number of patients (%)1 - 3 195 (65)4 - 6 104 (34.7)7 - 9 1 (0.3)Table III: Episodes of vomiting and diarrhea per 24 hours.Number of vomiting Number of Diarrheal episodes Number ofper 24 hours patients per 24 hours patientsn (%) n (%)2 - 4 37 (31.3) 04 - 07 51 (17)5 - 7 70 (59.3) 08 - 11 181 (60.3)8 - 10 11 (9.3) 12 -15 68 (22.7)Total episodes of vomiting 118 Total episodes of diarrhea 300Table IV:Association of clinical features of diarrhea with Rota virus  (n = 300).Patients Vomiting FeverPresent Absent Present AbsentRota virus +ven=188 51(27.1%) 137 (72.8%) 105 (55.8%) 83 (44.1%)Rota virus -ven=112 67 (59.8%) 45 (40.1%) 77 (68.7%) 35 (31.2%)P-value < 0.001 0.027Rota virus diarrhea in hospitalized childrenJournal of the College of Physicians and Surgeons Pakistan 2014, Vol. 24 (2): 114-117 117Available from: http://www.who.int/immunization/topics/rotavirus/en/index.html2. Malek MA, Teleb N, Abu-Elyazeed R, Riddle MS, Sherif ME,Steele AD, et al. The epidemiology of Rota virus diarrhea incountries in the Eastern Mediterranean Region. J Infect Dis2010; 202:S12-22.3. Shariff M, Deb M, Singh R. A study of diarrhea among childrenin Eastern Nepal with special reference to Rota virus. Indian JMed Microbiol 2003; 21:87-90.4. Ali NK, Bhutta ZA. A review of Rota virus diarrhea in Pakistan:how much do we know? J Coll Physicians Surg Pak 2003;13:297-301.5. WHO. Global and national estimates of deaths under age fiveattributable to Rota virus infection. Geneva: World HealthOrganization; 2006. 6. Morphy TV, Gargiullo PM, Massoudi MS, Nelson DB, JumaanAO, Okoro CA, et al. Intussusceptions among infants given anoral Rota virus vaccine. N Engl J Med 2001; 344:564-72.7. Parashar UD, Hummelman EG, Bresee JS, Miller MA, GlassRI. Global illness and deaths caused by Rota virus disease inchildren. Emerg Infect Dis 2003; 9:565-72.8. Agboatwalla M, Isomura S, Akram DS, Isihara Y, Sakae K,Yamashita T, et al. Enteric viral infections in pre-school childrenin Karachi, Pakistan. Indian J Pediatr 1995; 62:345-51.9. Yolken RH, Wyatt RG, Zissis G, Brandt CD, Rodriguez WJ,Kim HW, et al. Epidemiology of human Rota virus type 1 and 2as studied by enzyme-linked immunosorbent assay. N Engl JMed 1978; 299:1156-61.10. Dutta SR, Khalfan SA, Baig BH, Philipose L, Fulayfil R.Epidemiology of Rota virus diarrhea in children under fiveyears in Bahrain. Int J Epidemiol 1990; 19:722-7.11. Steele AD, Geyer A, Alexander JJ, Crewe-Brown HH, Fripp PJ.Enteropathogens isolated from children with gastro-enteritis atGa-Rankuwa Hospital, South Africa. Ann Trop Paediatr 1988;8:262-7.12. Parashar UD, Holman RC, Clarke MJ, Bresee JS, Glass RI.Hospitalizations associated with Rota virus diarrhea in theUnited States, 1993 through 1995, surveillance based on thenew TCD-9-CM Rota virus - specific diagnostic code. J InfectDis 1997; 177:13-7.13. Jain V, Das BK, Bhan MK, Glass RI, Gentsch JR. The Indianstrain surveillance collaborating laboratories: great diversityof group a Rota virus strains and high prevalence of mixedRota  virus infections in India. J Clin Microbiol 2001; 39:3524-9.14. Cunliffe NA, Kilgore PE, Bresee JS, Steele AD, Luo N, HartCA, et al. Epidemiology of Rota virus diarrhea in Africa: areview to assess the need for Rota virus immunization. BullWorld Health Organ 1998; 76:525-37.15. Perez-Schael I, Guntinas MJ, Perez M, Pagone V, Rojas AM,Gonzalez R, et al. Efficacy of the rhesus Rota virus-basedquadrivalent vaccine in infants and young children inVenezuela. N Engl J Med 1997; 337:1181-7.16. Kelkar SD, Purohit SG, Simha KV. Prevalence of Rota virusdiarrhea among hospitalized children in Pune, India. Indian JMed Res 1999; 109:131-5.17. Tate JE, Patel MM, Steele AD, Gentsch JR, Payne DC,Cortese MM, et al. Global impact of Rota virus vaccines.Expert Rev Vaccines 2010; 9:395-407.

Rota virus diarrhea in hospitalized children

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Rota virus diarrhea in hospitalized children

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