Study of clinical profile of rotaviral gastroenteritis among patients admitted in a tertiary care hospital

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Study of the incidence and clinical profile of rotaviral gastroenteritis.

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Study of clinical profile of rotaviral gastroenteritis among patients admitted in a tertiary care hospital

  1. 1. Study of clinical profile of rotaviral gastroenteritis among patients admitted in a tertiary care hospital
  2. 2. Original Article Study of clinical profile of rotaviral gastroenteritis among patients admitted in a tertiary care hospital Kochurani Abraham a , Sanjay Bafna b, *, Leena Hiremath c , Shailesh Muley d a Senior Registrar, Dept of Paediatrics, Jehangir Hospital (Apollo Group Hospital), Pune, India b Senior Consultant Paediatrician, HOD, Dept of Paediatrics, Jehangir Hospital (Apollo Group Hospital), Pune, India c Senior Consultant Paediatrician, Dept of Paediatrics, Jehangir Hospital (Apollo Group Hospital), Pune, India d DNB Resident, Dept of Paediatrics, Jehangir Hospital (Apollo Group Hospital), Pune, India a r t i c l e i n f o Article history: Received 19 October 2013 Accepted 14 February 2014 Available online 15 March 2014 Keywords: Rotavirus Gastroenteritis Infants Dehydration a b s t r a c t Objectives: To study the incidence and clinical profile of rotaviral gastroenteritis (RVGE) among patients admitted with acute gastroenteritis (AGE) in Jehangir hospital. Methods: 75 children aged 1 month to 5 years admitted with AGE during Jan 2012 to July 2013 were studied. Detailed history and clinical profile were documented. Their stool samples were sent for routine examination, rotaviral and adenoviral studies by immunochroma- tographic test. Results: We studied 75 children with AGE, of which, 27 (36%) were positive for rotavirus and 6 (8%) for adenovirus. Out of the 27 rotaviral diarrhea patients, 15 (55.5%) were infants, 10 (37%) were between 1 and 3 years and 2 (7.4%) were in 3e5 age group. There was clustering of cases in the first quarter of the year without any remarkable seasonal variability. The average duration of rotaviral diarrhea was 4.7 days and average hospital stay was about 3.8 days. None of these RVGE patients progressed to persistent diarrhea or required hospitalization beyond 7 days. The common presenting features were vomiting, loose motions and fever. The degree of dehydration was mild in all patients. Conclusion: This study documents the high incidence of rotaviral diarrhea in our popula- tion. It also highlights the fact that rotaviral diarrhea predominantly occurs in younger children, particularly infants. Early health care access and good nutritional status probably accounted for the mild disease in our population. Copyright ª 2014, Indraprastha Medical Corporation Ltd. All rights reserved. 1. Introduction Globally diarrhea is major cause of morbidity and mortality in children under 5 years.1 Diarrhea is third leading killer of in- fants and under five children in India and is responsible for 13% deaths in this age group.2 * Corresponding author. Dept of Paediatrics, Jehangir Hospital (Apollo Group Hospital), 32, Sassoon Road, Pune 411001, India. Tel.: þ91 9823005044. E-mail address: sanjaybafna16@gmail.com (S. Bafna). Available online at www.sciencedirect.com ScienceDirect journal homepage: www.elsevier.com/locate/apme a p o l l o m e d i c i n e 1 1 ( 2 0 1 4 ) 2 e5 http://dx.doi.org/10.1016/j.apme.2014.02.003 0976-0016/Copyright ª 2014, Indraprastha Medical Corporation Ltd. All rights reserved.
  3. 3. Rotavirus is the major cause of severe gastroenteritis in infants and young children worldwide. It is estimated that rotavirus disease is responsible for more than half million deaths annually among under five children. Majority of these deaths occur in developing countries.1 Rotavirus is leading cause of severe diarrhea in Indian children under 5 years and has been projected to cause large number of hospitalizations and 1.22e1.53 million deaths annually.3 Unlike many other pathogens, the proportion of diarrhea caused by rotavirus does not vary widely between developed and developing countries.4 However there are significant dif- ferences like age of first infection, serotypes, seasonality and severity of the disease.5,6 We studied the incidence and clinical profile of rotavirus gastroenteritis admitted in our hospital. 2. Methodology 2.1. Study site This study was conducted in Jehangir hospital (Apollo group hospital), Pune which is a tertiary care hospital catering mainly to middle and upper middle class urban population. 2.2. Enrollment criteria All children less than 5 years who were admitted in our hos- pital with acute gastroenteritis (AGE) from Jan 2012 to July 2013 were enrolled. Children with bacillary dysentery, chronic diarrhea and immunodeficiency were excluded. 2.3. Clinical assessment Detailed history and clinical profile were documented as per the proforma. Details of onset, frequency and duration of diarrhea, and other symptoms like fever, vomiting were recorded. Degree of dehydration and treatment details were recorded. Nutritional assessment was done by weight for age using WHO (World Health Organization) growth charts and IAP (Indian Academy of Paediatrics) classification for assess- ment of nutritional status. Stool samples were sent for routine examination, rotaviral and adenoviral studies by immuno- chromatographic test (RIDA QUICK Rotavirus/Adenovirus Combi kit). All stool samples were transported to laboratory within 2 hours and kept at 4 C until testing. Other in- vestigations were done as required. 3. Results 75 children were admitted with acute gastroenteritis out of which 27 (36%) were positive for rotavirus and 6 (8%) for adenovirus (Fig. 1). Out of 27 patients with rotaviral diarrhea 15 (55.5%) were 1 year, 10 (37%) were between 1 and 3 years and 2 (7.4%) were in 3e5 years age group. Amongst them, 18.5% were less than 6 months (Fig. 2). Of the 27 children with rotaviral gastroenteritis, 16 (59.2%) were boys and 11 (42.5%) were girls. There was clustering of cases in the months of January (14.8%), February (14.8%) and March (29.62%). During rest of the year, distribution of cases was similar (Fig. 3). All children were well nourished except one child who had grade I malnutrition. The average duration of diarrhea in rotavirus positive children was 4.7 days and their average duration of hospital stay was about 3.8 days. None of them progressed to persis- tent diarrhea or required hospitalization beyond 7 days. Patients presented with fever, loose motion, vomiting or combination of these. Out of the 27 children, 12 (44.44%) pre- sented with fever, loose motions and vomiting, 7 (25.92%) with loose motions and vomiting, 7 (25.92%) with loose motions and fever and 1 (3.7%) with only loose motions (Fig. 4). Degree of dehydration was mild in all children. 4. Discussion Rotavirus is an icosahedral RNA virus. Seven serogroups have been described (AeG). Group A rotaviruses cause most human disease (Fig. 5). Rotavirus is composed of 3 concentric protein shells surrounding the genome. The outermost layer of virus is composed of two surface proteins VP7 which determines the G serotype and VP4 which determines the P serotype. Each rotavirus strain is designated by its G serotype number fol- lowed by P serotype number.7 Fig. 1 e Incidence of rotaviral gastroenteritis in study site. Fig. 2 e Agewise incidence of rotavirus gastroenteritis in study site. a p o l l o m e d i c i n e 1 1 ( 2 0 1 4 ) 2 e5 3
  4. 4. There is wide variation in the strains causing rotavirus disease worldwide. Rotavirus isolates from India are geneti- cally heterogenous.8,9 The study done by Indian Rotavirus Strain Surveillance Network found that there is significant diversity in rotaviral strains causing RVGE in Indian population.10 In our study, the rotavirus was detected in 36% of all under five children admitted for gastroenteritis. Various studies have looked at the contribution of rotavirus to severe diarrhea in India.11e13 Review of 30 such studies done from 1976 to 1996 showed that nearly 18% of them were due to rotavirus and more recent reviews of 10 studies from 1999 to 2004 showed an inci- dence of 23.4% of rotaviral diarrhea in children admitted with gastroenteritis.13 A multicentre hospitalbased studyofrotaviral disease done by Kang et al in Indian children reported 39% incidence among under five children admitted for gastroen- teritis.10 2008 Asia Rotavirus Surveillance Network (ARSN) data from India shows that rotavirus contributes to as high as 39% of all cases causing diarrhea needing hospitalizations.14 It indicates that rotavirus is emerging as a leading cause of severe diarrhea as other etiological agents are controlled by better nutrition and hygiene. Improvement in sanitation and hygiene had a tremendous impact on diarrheal disease due to bacteria and parasites but less so on RVGE. This is because of the persistence of rotavirus in high income settings and is thought to be due to transmission through person-to-person contact which persists even as fecal-oral transmission diminishes.15 The study also documents early incidence of rotavirus disease in India. In our study highest percentage of patients were infants (55.5%) and 18.5% children were less than 6 months. 92% of the children were under 3 years. These results are similar to the findings from various Indian studies. Kang et al in India reported high incidence of rotavirus disease in the early age group.10 Study done by Velazquez et al also reported that majority (96%) of infections occur below 2 years and that subsequent infections were milder.16 Most of the rotavirus gastroenteritis in India occurs in first 2 years of life .In hospital based studies 87% of all rotaviral cases occurred by 18 months of age.17e20 Additionally only 13% cases were in children less then 6 months. However, outpatient and community based studies found higher pro- portion of cases (30%) in children less than 6 months.18,21 This difference is likely to be function of severity as in young children, infection may be attenuated by maternal antibodies and thus, severe disease is uncommon. These findings have clear implication for vaccination as immunity will need to be induced early in children in devel- oping countries for effective protection against RVGE. Most Indian studies have observed a seasonal variation with more cases in winter months throughout the coun- try.17,19,22 Studies in Pune and Chennai have observed sea- sonal variation despite their tropical climates.17,19 In our study there was clustering of cases in early quarter of the year, however definite seasonal pattern could not be documented. The clinical features of rotavirus diarrhea in our study matched those reported in the longitudinal cohort study in Fig. 3 e Graph showing month wise distribution of cases in study site. Fig. 4 e RVGE-presenting complaints. Fig. 5 e Rotavirus virion. a p o l l o m e d i c i n e 1 1 ( 2 0 1 4 ) 2 e54
  5. 5. Egypt.23 It was difficult to differentiate rotavirus infection from non-rotavirus gastroenteritis from clinical features alone. Apart from diarrhea, majority of patients (70%) had vomiting as the initial presentation. Vomiting is probably caused by stimulation of chemoreceptors in upper gastroin- testinal tract that may be activated by contraction or disten- tion of gut or by physical damage. Over a period of 1e2 days, viral replication and infection spreads further along the small intestine. Mucosal lesions are produced as a result of selective destruction of tips of villi lining the gut. This results in watery diarrhea and dehydra- tion. Diminished disaccharidase activity leads to malabsorp- tion.5,7 Majority of our children had disease duration of less than a week though in severe cases fever, vomiting and diarrhea are known to persist longer.24,25 Though RVGE is the major cause of severe dehydrating diarrhea; surprisingly most of our children had mild dehy- dration and had mild disease. This might be because of early health care access and good nutritional status of our study population. In summary, this study highlights the high prevalence of rotaviral diarrhea in our population. The study also docu- ments that majority of rotaviral diarrhea occur in infancy signifying the importance of early rotaviral vaccination. Early health care access and rehydration reduces morbidity and mortality associated with rotaviral gastroenteritis. Conflicts of interest All authors have none to declare. Acknowledgments Dr Vikram Padbidri, Consultant Microbiologist, Dept. of Microbiology, Jehangir Hospital, Pune. r e f e r e n c e s 1. Liu L, Johnson HL, Cousens S, et al. Global, regional and national causes of child mortality: an updated systematic analysis for 2010 with time trends since 2000. Lancet. 2012;379:2151e2161. 2. Bassani DG, Kumar R, Awasthi S, et al. Causes of neonatal and child mortality in India: a nationally representative mortality survey. Lancet. 2010;376:1853e1860. 3. Tate JE, Chitambar S, Esposito DH, et al. Disease and economic burden of rotavirus diarrhoea in India. Vaccine. 2009;27:F18eF24. 4. Parashar UD, Burton A, Lanata C, et al. Global mortality associated with rotaviral disease among children in 2004. J Infect Dis. 2009;200:S9eS15. 5. Linhares AC, Bresee JS. Rotavirus vaccine and vaccination in Latin America. Rev Panam Salud Publica. 2000;8:305e331. 6. Glass RI, Parashar UD, Breese JS, et al. Rotavirus vaccines: current prospects and future challenges. Lancet. 2006 Jul 22;368:323e332. 7. Parashar UD, Breese JS, Gentsch JR, Glass RI. Rotavirus. Emerg Infect Dis. 1998;4:561e570. 8. Das S, Varghese V, Chaudhuri S, et al. Genetic variability of human rotavirus strains isolated from Eastern and Northern India. J Med Virol. 2004;72:156e161. 9. Jain V, Das BK, Bhan MK, Glass RI, Gentsch JR. Great diversity of group A rotavirus strains and high prevalence of mixed rotavirus infections in India. J Clin Microbiol. 2001;39:3524e3529. 10. Kang G, Arora R, Chitambar SD, et al. Multicentre hospital- based surveillance of rotavirus disease and strains among Indian children aged 5 years. JID. 2009;200:S 147eS 153. 11. Jain V, Parashar UD, Glass RI, Bhan MK. Epidemiology of rotavirus in India. Indian J Pediatr. 2001;68:855e862. 12. Ramani S, Kang G. Burden of disease molecular epidemiology of group A rotavirus infections in India. Indian J Med Res. 2007;125:619e632. 13. Kang G, Kelkar SD, Chitambar SD, Ray P, Naik T. Epidemiological profile of rotaviral infection in India: challenges for the 21st century. J Infect Dis. 2005;192:S10eS126. 14. Proceedings of the Asia-Pacific Rotavirus MetaForum. 2007. 15. Chandran A, Fitzwater S, Zhen A, Santosham M. Prevention of rotavirus gastroenteritis in infants and children: rotavirus vaccine safety, efficacy and potential impact of vaccines. Biologics. 2010;4:213e229. 16. Velazquez FR, Matson DO, Calva JJ, et al. Rotavirus infections in infants as protection against subsequent infections. N Engl J Med. 1996;335:1022e1028. 17. Kelkar SD, Purohit SG, Simha KV. Prevalence of rotavirus diarrhoea among hospitalised children in Pune, India. Indian J Med Res. 1999;109:131e135. 18. Kelkar SD, Purohit SG, Boralkar AN, Verma SP. Prevalence of rotavirus diarrhoea among outpatients and hospitalised patients: a comparison. Southeast Asian J Trop Med Public Health. 2001;32:494e499. 19. Saravanan P, Ananthan S, Ananthasubramanian M. Rotavirus infections among infants and young children in Chennai, South India. Indian J Med Microbiol. 2004;22:212e221. 20. Kang G, Green J, Gallimore CI, Brown DW. Molecular epidemiology of rotaviral infection in South Indian children with acute diarrhoea from 1995e1996 to 1998e1999. J Med Virol. 2002;67:101e105. 21. Banerjee I, Ramani S, Primrose B, et al. Comprative study of the epidemiology of rotavirus in children from a community based birth cohort and a hospital in South India. J Clin Microbiol. 2006;44:2468e2474. 22. Bahl R, Ray P, Subodh S, et al. Incidence of severe rotavirus diarrhoea in New Delhi, India, and G and P types of the infecting rotavirus strains. J Infect Dis. 2005;192:S114eS119. 23. Naficy A, Abu-Elyazeed R, Holmes J, et al. Epidemiology of rotavirus diarrhoea in Egyptian children and implication of disease control. Am J Epidemiol. 1999;150:770e777. 24. Kapikian A, Chanock R. Rotaviruses. In: Knipe DM, Howley PM, eds. Field Virology. 4th ed. Lippincott Williams Wilkins; 2001:1787e1834. 25. Robert B. Rotavirus, enteric adenoviruses other viruses causing gastroenteritis. 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