Nosocomial rotavirus infections: a systematic review

[Nosocomial rotavirus gastroenteritis]

Rotavirus is the most common cause of gastroenteritis in children requiring hospitalization. It is a very resistant and contagious virus causing nosocomial gastroenteritis. In France, the vaccine against rotavirus has been available since 2006, but the vaccine is not recommended for infant vaccination. The aim of this retrospective study was to describe nosocomial rotavirus gastroenteritis (NRGE) and to assess its impact on children hospitalized in the General Pediatrics Department of Robert-Debré Hospital (Paris) between 1 January 2009 and 31 December 2013. We analyzed the demographic characteristics of children (age, term birth, underlying diseases) and the severity of the NRGE (oral or intravenous hydration), and assessed whether these children could benefit from vaccination against rotavirus.

RESULTS

One hundred thirty-six children presented nosocomial rotavirus infection, with an incidence of 2.5 NRGE per 1000 days of hospitalization. The incidence of NRGE was stable between 2009 and 2013 despite the introduction of specific hygiene measures. The average age of the children was 7 months (range: 0.5-111 months). Most often NRGE occurred in children hospitalized for respiratory diseases (65% of cases) and requiring prolonged hospitalization (median: 18 days). One-third of children were born premature (25%). Hydration was oral in 80 patients (59%), by intravenous infusion in 18 patients (13%), and intraosseous in one patient. Half of the patients were aged less than 5 months and could benefit from the protection afforded by vaccination.

CONCLUSION

NRGE are common. Rotavirus mass vaccination should have a positive impact on the incidence of NRGE by reducing the number of children hospitalized for gastroenteritis, therefore indirectly reducing the number of hospital cross-infections of hospitalized children who are too young to be vaccinated.

Rotavirus Genotypes and Vaccine Effectiveness from a Sentinel, Hospital-Based, Surveillance Study for Three Consecutive Rotavirus Seasons in Lebanon

Introduction

Globally, rotavirus (RV) is the leading cause of gastroenteritis (GE) in children. Longitudinal data about changes in RV genotype distribution and vaccine effectiveness (VE) are scarce. This study was conducted in Lebanon over 3 consecutive RV seasons to estimate the rate of RVGE hospitalization, identify RV genotypes, determine the seasonal and geographical variations, and calculate RV VE.

Materials and Methods

This prospective, multicenter, hospital-based surveillance study was conducted between 2011 and 2013 and enrolled children (<5 years) admitted for GE. Socio-demographic and clinical data about the current episode of GE at admission were collected. Genotypes were determined from stool samples testing positive for RV by PCR.

Results

Of 1,414 cases included in the final analysis, 83% were <2 years old and 55.6% were boys. Median duration of hospitalization was 4 days and 91.6% of GE cases were severe (Vesikari score ≥11). PCR testing showed that 30.3% of subjects were RV-positive of which 62.1% had fever versus 71.1% of RV-negative subjects (P = 0.001). RV was predominantly detected in the cold season from November till March (69.9%). G and P genotype pairs for all RV-positive stool specimens showed a predominance of G1P[8] in 36% (n = 154) of specimens, G9P[8] in 26.4% (n = 113), and G2P[4] in 17.8% (n = 76). RV-negative subjects were more likely to be RV-vaccinated (21%) compared to the RV-positive subjects (11.3%) (P<0.001), with a vaccine breakthrough rate of 18.8%. The ratio of RV1-vaccinated for each RV5-vaccinated subject was 7.8 and VE against RV disease was 68.4% (95%CI, 49.6%-80.2%).

Conclusion

RV is a major cause of GE requiring hospitalization of children under 5 years of age in Lebanon. A few genotypes predominated over the three RV seasons studied. Mass RV vaccination will likely decrease the burden of hospitalization due to RV. VE is similar to what has been observed for other middle-income countries.

Nosocomial rotavirus infection: An up to date evaluation of European studies

Rotavirus (RV) is worldwide considered as the most important viral agent of acute gastroenteritis in children less than 5 y. Since 2006, the availability of anti-RV vaccines has deeply modified the incidence and economic burden of RV infection. In Europe, some countries have introduced an anti-RV vaccination program in the last 10 y. Although community acquired RV (CARV) disease is the most studied condition of RV infection, recently some authors have highlighted the importance of nosocomial RV (nRV) disease as an emerging public health issue. The aim of this review is to summarize the epidemiology of both CARV and nRV, in order to discuss the difficulty of a clear evaluation of the burden of the disease in absence of comparable data. In particular, we focused our attention to European studies regarding nRV in terms of divergences related to definition, report of incidence rate and methodological issues.

Rotavirus Gastroenteritis in a Neonatal Unit of a Greek Tertiary Hospital: Clinical Characteristics and Genotypes

INTRODUCTION

Rotavirus (RV) infection in neonatal age can be mild or even asymptomatic. Several studies have reported that RV is responsible for 31%-87% of pediatric nosocomial diarrhea and causes gastroenteritis outbreaks in pediatric and neonatal units.

OBJECTIVES

Study clinical characteristics, genotypes and risk factors of RV infection in neonatal age.

METHODS

A prospective study was conducted from April 2009 till April 2013 in the neonatal special care unit of the largest tertiary pediatric hospital of Greece. Fecal samples and epidemiological data were collected from each neonate with gastrointestinal symptoms. RV antigen was detected with a rapid immunochromatography test. RV positive samples were further genotyped with RT PCR and sequencing using specific VP7 and VP4 primers.

RESULTS

Positive for RV were 126/415 samples (30.4%). Mean age of onset was 18 days. Seventy four cases (58%) were hospital acquired. Seasonality of RV infection did not differ significantly throughout the year with the exception of 4 outbreaks. Genotypes found during the study period were G4P[8] (58.7%), G1P[8] (14.7%), G12P[8] (9.3%), G3P[8] (9.3%), G12P[6] (5.3%), G9P[8] (1.3%) and G2P[4] (1.3%). RV cases presented with: diarrhea (81%), vomiting (26.2%), fever (34.9%), dehydration (28.6%), feeding intolerance (39.7%), weight loss (54%), whilst 19% of cases were asymptomatic. Comparing community with hospital acquired cases differences in clinical manifestations were found.

CONCLUSIONS

Significant incidence of nosocomially transmitted RV infection in neonatal age including asymptomatic illness exists. Genotypes causing nosocomial outbreaks are not different from community strains. Circulating vaccines can be effective in prevention of nosocomial RV infection through herd immunity.

Additive impact of pneumococcal conjugate vaccines on pneumonia and empyema hospital admissions in England

OBJECTIVES

A wider spectrum 13-valent pneumococcal vaccine (PCV13) replaced PCV7 in the child immunization schedule in England from 2010. We assessed the additional impact of PCV13 over PCV7 on all-cause pneumonia and empyema admissions.

METHODS

We extracted Hospital Episode Statistics data from 2001 to 2014 on all-cause pneumonia (ICD-10 codes J12-18) and empyema admissions (J86.0, J86.9) for children <16 years in England. Trend analysis and rate ratios (RR) were calculated comparing the Pre-vaccine era to September 2006, the PCV7 era and the PCV13 era from April 2010.

RESULTS

Annual hospital admissions for pneumonia and empyema were increasing in the Pre-vaccine era peaking in 2005 at 15,733 pneumonia and 382 empyema cases (158.6 and 3.9 per 100,000 children, respectively). These rates fell following PCV7 introduction in 2006 but began to climb soon afterwards until PCV13 was introduced. By 2013, admission rates for pneumonia and empyema were 102.2 and 1.9 per 100,000 children, respectively. We found no added benefit of PCV13 over PCV7 on pneumonia admissions following PCV13 introduction but there was a significant decrease in empyema admissions in children aged <2 years (RR 0.58; 95% CI 0.34-0.99).

CONCLUSIONS

Additional serotypes covered by PCV13 may be more important in the aetiology of empyema and invasive disease than as a cause of uncomplicated pneumonia.

The coincidence of necrotizing enterocolitis and rotavirus infections and potential associations with cytokines

BACKGROUND

Necrotizing enterocolitis (NEC) is the most common gastrointestinal disease in neonatal intensive care units. Although the pathogenesis of NEC remains unclear, evidence suggests that infections, especially bacterial infections, may play an important role. Viral infections may also result in NEC. Several outbreaks of NEC associated with rotaviruses have been described previously.

OBJECTIVE

To investigate the association between rotavirus (RV) and serum interleukin (IL)-6 and IL-8 levels in infants with NEC.

METHODS

RV infections were prospectively studied using antigen detection in the stools of 31 infants with NEC. Additionally, serum levels of IL-6, IL-8 and tumour necrosis factor-alpha were tested using micro-ELISA at 0 h and 48 h after diagnosis of NEC.

RESULTS

Fecal specimens from 13 infants were positive, while fecal specimens from 18 infants were negative for RV according to antigen detection (RV+ and RV- groups, respectively). The mortality rate and the severity of NEC were not significantly different between the RV+ and RV- groups. IL-6 levels at 0 h and 48 h after diagnosis of NEC in RV+ infants were lower compared with RV- infants, while IL-8 levels were greater at 0 h and 48 h after diagnosis of NEC in RV+ infants compared with RV- infants.

CONCLUSION

A high prevalence of RV infection in neonates with NEC was found. Decreased IL-6 levels and increased IL-8 and tumour necrosis factor-alpha levels in RV+ neonates with NEC suggests a role for RV in NEC.

Clinical manifestations of a cluster of rotavirus infection in young infants hospitalized in neonatal care units

PURPOSE

To define the clinical manifestations of rotavirus (RV) infection in neonates and young infants hospitalized in neonatal care units, which are rarely reported.

MATERIALS AND METHODS

From October 2008 to September 2010, a total of 153 stool specimens positive for RV were detected from 100 neonates and young infants hospitalized in neonatal care units of our hospital. Four infants had two episodes of RV infection. Demographics and clinical presentations of these infants were collected and analyzed. The infants were further classified as having hospital-acquired (HA) or community-acquired (CA) RV infection.

RESULTS

Of the 104 episodes from 100 patients, 76 (73%) were classified as HA. Fifty-six infants were male. The mean age of onset was 2 days. The most common presentations were loose stool passages (52.9%), abdominal distension (51.9%), blood or mucus in stool (42.3%), and unstable vital signs (32.7%). Watery character in stool passage was identified in 13.5% of the infants and vomiting in 21.2%. A picture suggestive of necrotizing enterocolitis (NEC) was identified in 22 episodes (21.1%), and 12 of these were stage II or above. The average number of hospitalization days from the onset of HA-RV infection was 23 days. Compared with those in the CA group, the infants in the HA group had a significantly higher rate of blood or mucus in stools (52.6% vs. 14.3%, p < 0.01) and unstable vital signs (39.5% vs. 14.3%, p = 0.02), but a lower rate of watery diarrhea (9.2% vs. 28.6%, p = 0.04) and fever (13.8% vs. 42.9%, p < 0.01). Overall, there were five deaths, but all of these infants had major diseases.

CONCLUSION

Bloody, mucoid stools and unstable vital signs, instead of fever with watery diarrhea, are commonly seen in neonates and young infants with RV infection. A substantial proportion of these infants may present as NEC. Once introduced, RV appears to become a troublesome problem of HA infections in neonatal care settings.

A community outbreak of rotavirus diarrhea associated with exposures in a hospital outpatient department in South China

INTRODUCTION

Between October 1 and December 10, 2006, Bao'an, China had a 5-fold increase in acute rotavirus gastroenteritis (ARGE) cases compared with the same time in 2005. To identify the risk factors for ARGE during this outbreak, we conducted a case-control study among children ≤ 24 months old from the most heavily affected area.

METHODS

We defined an ARGE case as diarrhea, with group A rotavirus antigen detected from fecal samples by the enzyme-linked immunosorbent assay test. In the case-control study, 86 confirmed ARGE cases were identified. We enrolled 98 healthy control children matched by age. We administered questionnaires about exposures through telephone interviews.

RESULTS

Of 8 general exposure types, we identified the following as being associated with ARGE: visiting outpatient services of hospital X, odds ratio (OR) = 7.1 (95% confidence interval [CI], 2.2-26); contact with other children with diarrhea, OR = 2.1 (95% CI, 1.1-3.7); and hand-washing before eating, OR = 0.48 (95% CI, 0.27-0.82). After improvements in the outpatient department of hospital X, ARGE incidence in the community during the ARGE transmission season (October through December) decreased from 4.3/10000 in 2006 to 1.4/10000 in 2009.

CONCLUSIONS

Outpatient services in hospital X may have contributed to the transmission of ARGE and improvements in infection control practices in this setting were associated a marked decrease incidence of ARGE in this community.

Decline in rotavirus hospitalisations following introduction of Australia's national rotavirus immunisation programme

AIM

To determine the impact of rotavirus immunisation on rotavirus hospitalisations in young children. methods: Annual hospitalisations for rotavirus gastroenteritis to The Children's Hospital at Westmead, a tertiary care paediatric hospital in Sydney, were recorded from 2001 for 6 years prior to and 2.5 years following the introduction of rotavirus vaccines to the National Immunisation Program. Data on hospital-acquired rotavirus gastroenteritis were collected prospectively.

RESULTS

Hospitalisations for rotavirus gastroenteritis declined in the two full rotavirus seasons (2008 and 2009) after vaccine introduction by 75% compared with mean annual hospitalisations from 2001 to 2006. The greatest decline was seen in those <12 months of age (93%), but the reduction occurred consistently across all age groups, even in children not eligible for immunisation, suggesting an effect on herd immunity. A substantial decline in nosocomial rotavirus gastroenteritis was seen from 2007 to 2009, suggesting a reduction in virus transmission in the hospital setting.

CONCLUSION

This study demonstrates a substantial reduction in hospitalisations in children of all ages to a large paediatric hospital and reduced nosocomial infections since the introduction of a nationally funded rotavirus immunisation programme in Australia.

Hospital acquired rotavirus infections: burden in Canadian paediatric hospitals

Rotavirus infections are one of the most common hospital acquired infections in pediatric hospitals. Laboratory confirmed hospital acquired rotavirus infections from 12 pediatric hospitals in Canada were documented for a 3 year period, 2005-7. Overall, hospital acquired infections represented one quarter of all rotavirus hospitalizations for an annual rate of 0.45 per 1000 hospital days with a peak of 0.68 per 1,000 hospital days between December and May. Approximately 8% developed symptoms <72 hours after hospital discharge and required admission to hospital for management of rotavirus infection. Sixty percent of cases were less than 1 year of age and 75% had underlying medical illnesses. Given the licensure and increasing use of rotavirus vaccines, baseline data on the incidence and epidemiology of hospital acquired rotavirus infections will be useful in order to determine the potential impact of vaccination on hospital acquired rotavirus.

Impact of rotavirus vaccination on hospital-acquired rotavirus gastroenteritis in children

OBJECTIVE

Data show that after the implementation of routine rotavirus vaccination for infants in the United States, community-acquired (CA) rotavirus cases declined substantially in the 2007-2008 season. The impact of community-based rotavirus vaccination on the substantial burden of hospital-acquired (HA) rotavirus has not been documented.

PATIENTS AND METHODS

We assessed CA and HA rotavirus, respiratory syncytial virus, and influenza infections at Children's Memorial Hospital for 5 winter seasons (defined as occurring from September through May) from 2003 to 2008. We also report rotavirus data from the 2008-2009 season.

RESULTS

A similar dramatic decline (>60% compared with the median of previous seasons) occurred in the rates of cases of both CA (P < .0001) rotavirus hospitalizations and HA (P < .01) rotavirus infections in the 2007-2008 season compared with previous seasons, whereas the rates of CA and HA influenza and respiratory syncytial virus, respectively, remained stable. Improvements in hand-hygiene compliance did not correlate with a reduction in the transmission rate of rotavirus in the hospital. Both CA and HA rotavirus rates remained much lower in the 2008-2009 than in the 2003-2007 seasons.

CONCLUSIONS

Community-based rotavirus vaccination is associated with a substantial reduction in the number of children who are admitted with rotavirus. These data also indicate that routine community-based rotavirus infant vaccination protects hospitalized children from acquiring rotavirus. Vaccination efforts should be encouraged as a strategy to affect the substantial burden of HA rotavirus.

Dynamic model of rotavirus transmission and the impact of rotavirus vaccination in Kyrgyzstan

New rotavirus vaccines show promise to reduce the burden of severe diarrhea among children in developing countries. We present an age-specific dynamic rotavirus model to assess the effect of rotavirus vaccination in Kyrgyzstan, a country in Central Asia that is eligible for funds from the GAVI Alliance. A routine rotavirus vaccination program at 95% coverage and 54% effectiveness against severe infection is estimated to lead to a 56% reduction in rotavirus-associated deaths and a 50% reduction in hospital admissions, while outpatient visits and homecare episodes would decrease by 52% compared to baseline levels after 5 years of intervention. A 10% reduction in vaccine efficacy due to incomplete 3-dose regimen is estimated to increase the numbers of severe cases by 6-8%. Herd immunity was found to account for 1% or less of averted cases of severe gastroenteritis, while an extra 7-8% of all rotavirus infections would be avoided due to reduced transmission.

CONCLUSION

Rotavirus vaccines would reduce the burden of rotavirus disease substantially, but the results are sensitive to delay in age-appropriate vaccination.

[Toward the elimination of rotavirus gastroenteritis by universal vaccination]

Rotavirus is the most important cause of severe gastroenteritis in children worldwide, and is most effectively controlled by vaccines. The Strategic Advisory Group of Experts (SAGE) of the World Health Organization (WHO) recommended, in 2009, the inclusion of rotavirus vaccination of infants into all national immunization programs. Two, live, orally-administrable vaccines are licensed globally. They are Rotarix, a G1P[8] monovalent, human rotavirus-based vaccine (GlaxoSmithKline), and RotaTeq, a pentavalent, bovine-human reassortant vaccine (Merck). Although the two vaccines are very different in antigenic composition and administration schedule, they are almost equally safe with respect to intussusception and 90-100% efficacious against severe rotavirus diarrhea. Countries where either vaccine was introduced into the national childhood immunization program have witnessed not only a drastic decrease in the number of rotavirus hospitalizations but a near 50% reduction in the number of all-cause-diarrhea hospitalizations. Rotavirus diarrhea, an emerging infectious disease because of its discovery in 1973, may now be among vaccine preventable diseases.

Modeling nosocomial transmission of rotavirus in pediatric wards

Nosocomial transmission of viral and bacterial infections is a major problem worldwide, affecting millions of patients (and causing hundreds of thousands of deaths) per year. Rotavirus infections affect most children worldwide at least once before age five. We present here deterministic and stochastic models for the transmission of rotavirus in a pediatric hospital ward and draw on published data to compare the efficacy of several possible control measures in reducing the number of infections during a 90-day outbreak, including cohorting, changes in healthcare worker-patient ratio, improving compliance with preventive hygiene measures, and vaccination. Although recently approved vaccines have potential to curtail most nosocomial rotavirus transmission in the future, even short-term improvement in preventive hygiene compliance following contact with symptomatic patients may significantly limit transmission as well, and remains an important control measure, especially where resources are limited.

Recognition and prevention of hospital-associated enteric infections in the intensive care unit

The objectives of this article were to review the causes and extent of hospital-associated infectious diarrhea and associated risks in the general hospital ward and intensive care unit (ICU), to compare microorganisms with similar symptoms to aid in recognition that will lead to timely and appropriate treatment and control measures, and to propose infection prevention protocols that could decrease human process errors in the ICU. This literature review describes epidemiology, comparison of microbial characteristics for potential hospital-associated enteric pathogens, diagnosis, and prevention, especially if important in the ICU, and particularly in regard to Clostridium difficile. Enteric organisms that most commonly cause hospital-associated infectious diarrhea in acute care settings and the ICU are C. difficile, rotavirus, and norovirus, although others may also be important, particularly in developing countries. To recognize and control infectious diarrhea successfully in the ICU, intensivists should be aware that epidemiology, risks, and prevention measures may differ between these microorganisms. In addition, intensivists should be ready to implement systems changes related to notification, isolation precautions and prevention, and environmental cleaning in the ICU.

Genetic variation of G4P[6] rotaviruses: evidence for novel strains circulating between the hospital and community

One hundred forty-six fecal specimens collected between 2007 and 2008 from infants with acute gastroenteritis were screened for rotavirus by ELISA with VP6-specific antibody. One hundred twenty-three of the samples (84.2%) were confirmed to be positive for group A rotavirus (community-acquired, n = 90 [73.2%] and nosocomial, n = 33 [26.8%]), and were typed subsequently using RT-PCR and sequence analysis methods. Determination of G- and P-type combinations showed that G4P[6] (78.9%) was the most common strain, followed by G3P[8] (7.3%), G1P[8] (6.5%), G2P[4] (0.8%), G2P[6] (0.8%), G1P[6] (0.8%), and G9P[8] (0.8%) strains. Of the 97 G4P[6] strains, 62 (63.8%) were responsible for community-acquired cases and 35 (36.1%) were hospital-acquired cases. Phylogenetic analysis of the VP7 gene from the G4P[6] strains revealed that both the community-acquired and nosocomial strains were segregated to the human rotaviruses circulating world-wide, including the prototype vaccinal strain, ST3, which constituted a novel sublineage in lineage 1. Owing to the recent emergence of G4P[6] rotaviruses within the hospital, as well as in the community, the findings from this study are important since they provide new information concerning the community and nosocomial spread of rotaviruses.

Healthcare-associated viral gastroenteritis among children in a large pediatric hospital, United Kingdom

Enteric viruses introduced from the community are major causes of these illnesses.

Viruses are the major pathogens of community-acquired (CA) acute gastroenteritis (AGE) in children, but their role in healthcare-associated (HA) AGE is poorly understood. Children with AGE hospitalized at Alder Hey Children’s Hospital, Liverpool, UK, were enrolled over a 2-year period. AGE was classified as HA if diarrhea developed >48 hours after admission. Rotavirus, norovirus, adenovirus 40/41, astrovirus, and sapovirus were detected by PCR. A total of 225 children with HA-AGE and 351 with CA-AGE were enrolled in the study. HA viral gastroenteritis constituted one fifth of the diarrheal diseases among hospitalized children and commonly occurred in critical care areas. We detected >1 virus in 120 (53%) of HA-AGE cases; rotavirus (31%), norovirus (16%), and adenovirus 40/41 (15%) were the predominant viruses identified. Molecular evidence indicated rotaviruses and noroviruses were frequently introduced into the hospital from the community. Rotavirus vaccines could substantially reduce the incidence of HA-AGE in children.

Nosocomial rotavirus gastroenteritis in Spain: a multicenter prospective study

BACKGROUND

The objective of this study was to assess the incidence of nosocomial rotavirus gastroenteritis among children <2 years of age.

METHODS

We conducted a prospective active surveillance for acute gastroenteritis (AGE) in the pediatric wards of 3 representative hospitals in Valencia (Spain) from October 2006 to March 2007, among children between 1 and 23 months of age with acute diarrhea. Children were followed up for 3 days after discharge. We obtained clinical and demographic information from participants and tested their stool specimens for rotavirus.

RESULTS

A total of 1576 children were hospitalized at the 3 hospitals and 1300 (82.5%) were followed up as the study cohort. In 69 children, AGE started 48 hours after admission and were considered nosocomial infections. In 35 of the 59 cases where stool samples were obtained, rotavirus (RV) was present (59%), and in 12 of them symptoms started after discharge. The accumulated incidence of nosocomial rotavirus disease during the study period was 2.8 cases per 100 inpatients (95% CI: 1.9-3.8), and the incidence rate was 4.8 cases per 1000 hospital days (95% CI: 3.2-6.5). The most commonly found genotype in nosocomial infection was G9P[8], in 23 cases (66%), followed by G1P[8] in 4 cases (11%). The total economic cost was 883 euro per case.

CONCLUSION

Active surveillance demonstrated that the burden of nosocomial rotavirus disease is substantial, and G9P [8] was the genotype found most frequently. Following up children after discharge from hospital allowed the discovery of cases of nosocomial RVAGE which are missed in most other studies.

Licensed Vaccines for Rotavirus Prevention in the US: A Review

Objective:

To review the pharmacology, efficacy, safety, and tolerability of RotaTeq and RotaRix, 2 rotavirus vaccines.

Data Sources:

English-language articles were obtained via MEDLINE (1966-August 2009) and EMBASE (1980-August 2009) searches using the key words rotavirus vaccine, epidemiology, diarrhea, intussusception, RotaShield, RotaTeq, and RotaRix. Bibliographies of selected articles were used to identify additional sources.

Study Selection and Data Extraction:

Available published articles reporting the results of human studies of rotavirus vaccines were reviewed for inclusion in this article. Additional information regarding clinical trials and adverse events was obtained from the manufacturer's prescribing information for each vaccine.

Data Synthesis:

RotaTeq is a live, attenuated human-bovine pentavalent vaccine, and RotaRix is a live, attenuated human vaccine. Both vaccines are approved for the prevention of rotavirus infection and recommended for routine immunization in healthy infants aged 14 weeks to 8 months. The vaccines differ in virologic characteristics, but clinical trials indicate similar efficacy and safety. Each vaccine is more than 70% effective in preventing any severity of rotavirus gastroenteritis and more than 98% effective in preventing severe disease through one full season of rotavirus exposure postvaccination. Efficacy begins to wane during the second season of rotavirus exposure. Post hoc analyses of clinical trials indicated an 85–100% reduction in hospitalizations and emergency department visits following vaccination. Both vaccines have been well tolerated. Fever, vomiting, and diarrhea are the most reported adverse events. Intussusception and Kawasaki syndrome have been reported, but occurrence of these events has not been shown to be significant in comparison with the background rate for each adverse event.

Conclusions:

RotaTeq and RotaRix are effective for the prevention of rotavirus infection in the US, Europe, and Latin America. Additional studies are needed to assess their duration of protection, worldwide efficacy, effect on the reduction of healthcare resource utilization, and adverse event monitoring.

Budget impact and cost-effectiveness of including a pentavalent rotavirus vaccine in the New Zealand childhood immunization schedule

OBJECTIVES

To estimate: 1) rotavirus disease burden in New Zealand children aged under 5 years, and 2) health benefits, budget impact, and cost-effectiveness of incorporating a pentavalent rotavirus vaccine (PRV) into the national immunization schedule.

METHODS

A static equilibrium model was developed to evaluate health benefits and budget impact of vaccinating five successive birth cohorts with PRV at $50 per dose and 85% coverage (three doses). Cost-effectiveness was estimated from the societal perspective in year 5 of the program, with future health benefits discounted at 3.5% per annum.

RESULTS

By the age of 5 years, one in five children will have sought medical advice for rotavirus gastroenteritis and one in 43 will have been hospitalized. In 2009, we estimate 1506 hospitalizations (476 per 100,000; 95% confidence interval 451, 502), 3086 Emergency Department (ED) presentations not requiring hospitalization, plus 10,120 cases of rotavirus gastroenteritis managed solely in primary care. The annual societal cost is $7.07 million, including 41% from hospitalization and 25% from caregiver income loss. Health benefits will increase and the cost of illness will decline by 78% in year 5 as successive birth cohorts are immunized. In the fifth year, 1191 hospitalizations, 2442 ED treated cases, 9762 primary care consultations, and 0.8 deaths will be averted. It requires six vaccinated children to avoid one primary care consultation, 49 to avert one hospitalization, and 73,357 to prevent one death. The incremental cost is $2.99 million and the break-even price per vaccine dose is $32.39 at 2006 prices. The cost is $2509 to avert one hospitalization and $305 to prevent one case seeking health-care assistance. The cost per life-year gained in year 5 is $143,097 and the cost per quality-adjusted life-year (QALY) gained is $46,092 (US$26,774). The cost per QALY is sensitive to incidence rates, vaccine price and efficacy, loss of quality of life by the child, case fatality, and caregiver income loss.

CONCLUSIONS

From a societal perspective, addition of PRV to the New Zealand childhood immunization schedule would confer important clinical gains at a modest cost per QALY gained.

Hospitalizations for nosocomial rotavirus gastroenteritis in a tertiary pediatric center: a 4-year prospective study

BACKGROUND

Although rotavirus is the most common cause of gastroenteritis worldwide, data regarding nosocomial rotavirus gastroenteritis (NRVGE) are limited. Our objectives were to study the rates, seasonality, epidemiology, and clinical features of NRVGE.

METHODS

This was a 4-year prospective study.

RESULTS

NRVGE occurred in 1% of all admissions (356/35,833), 0.8% of all hospitalization days (1164/145,595) and 0.24 cases per 100 hospitalization days. Rates of NRVGE were age-dependent, occurring in 1.8%, 1.5%, 0.3%, and 0.1% of the admissions of children age < or = 1, > 1 to 2, > 2 to 5, and > 5 years, respectively (P < .001). Of the children age > 5 years, 90% received immunosuppressive treatment or had significant underlying diseases. The number of NRVGE cases was highest in winter months, but it occurred throughout the year, and its percentage of all hospitalizations for rotavirus gastroenteritis was highest in the summer months. NRVGE occurred after a median hospitalization of 6 days, required a median hospital stay of 3 days, and warranted treatment with intravenous fluids in 67% of cases.

CONCLUSION

NRVGE is a significant health burden, especially in children age < or = 2 years, although it also can affect children age > 5 years with significant underlying disturbances. Vaccine prevention of rotavirus gastroenteritis also could reduce NRVGE and should be considered in cost-effectiveness analyses.

Rotaviruses: from pathogenesis to vaccination

Rotaviruses cause life-threatening gastroenteritis in children worldwide; the enormous disease burden has focused efforts to develop vaccines and led to the discovery of novel mechanisms of gastrointestinal virus pathogenesis and host responses to infection. Two live-attenuated vaccines for gastroenteritis (Rotateq [Merck] and Rotarix) have been licensed in many countries. This review summarizes the latest data on these vaccines, their effectiveness, and challenges to global vaccination. Recent insights into rotavirus pathogenesis also are discussed, including information on extraintestinal infection, viral antagonists of the interferon response, and the first described viral enterotoxin. Rotavirus-induced diarrhea now is considered to be a disease that can be prevented through vaccination, although there are many challenges to achieving global effectiveness. Molecular biology studies of rotavirus replication and pathogenesis have identified unique viral targets that might be useful in developing therapies for immunocompromised children with chronic infections.

OUR COMMON ENEMY: COMBATTING THE WORLD'S DEADLIEST VIRUSES TO ENSURE EQUITY HEALTH CARE IN DEVELOPING NATIONS

In a previous issue of Zygon (Carvalho 2007), I explored the role of scientists-especially those engaging the science-religion dialogue-within the arena of global equity health, world poverty, and human rights. I contended that experimental biologists, who might have reduced agency because of their professional workload or lack of individual resources, can still unite into collective forces with other scientists as well as human rights organizations, medical doctors, and political and civic leaders to foster progressive change in our world. In this article, I present some recent findings from research on three emerging viruses-HIV, dengue, and rotavirus-to explore the factors that lead to the geographical expansion of these viruses and the increase in frequency of the infectious diseases they cause. I show how these viruses are generating problems for geopolitical stability, human rights, and equity health care for developing nations that are already experiencing a growing poverty crisis. I suggest some avenues of future research for the scientific community for the movement toward resolution of these problems and indicate where the science-religion field can be of additional aid.

Identification of risk factors associated with nosocomial infection by rotavirus P4G2, in a neonatal unit of a tertiary-care hospital

A rotavirus outbreak in newborns admitted to the 'La Paz' University Hospital, Madrid was detected, followed up and controlled. Uninfected children were selected as control subjects. Samples of faeces were taken once or twice weekly from all the newborns, including those who were asymptomatic and who were admitted to the neonatal unit for early detection of rotavirus and the positive were separated from the rest of the neonates. Contact-related precautions were taken for all patients, and alcohol solutions were used for hand washing. During the months of the outbreak, 1773 children were admitted to the hospital, 131 of whom were affected by the rotavirus infection (7.4%). Of these, 72 (55%) had symptomatic infections. In the first month of the outbreak, nine cases of necrotizing enterocolitis were diagnosed (one patient developed massive intestinal necrosis). The infections (symptomatic and asymptomatic) presented a bimodal distribution caused by a new outbreak of rotavirus type P4G2 after two patients who had acquired the infection outside the hospital were admitted when the first outbreak was subsiding. The characteristics of cases and controls were analysed using bivariate and multivariate methods (non-conditional multivariate logistic regression) to identify four risk factors strongly associated with rotavirus infection: premature birth, infections other than rotavirus, malformation, and changes in glycaemia and/or presence of jaundice.

[Infectious acute gastroenteritis in the emergency department of an urban hospital]

OBJECTIVES

To examine the etiology, clinical, analytical and evolutionary characteristics of gastroenteritis in the pediatric population in the Emergency Department of Dr. Peset University Hospital in Health Care Area 10 in Valencia, Spain, over a 1-year period (2005).

PATIENTS AND METHODS

Children < 15 years of age with acute diarrhea were prospectively enrolled in the Emergency Department. Data were collected through information sheets. Their stools were examined for diarrheagenic bacteria and viruses (rotavirus and adenovirus).

RESULTS

794 episodes of gastroenteritis were recorded. The incidence of rotavirus was 22 %, adenovirus 8 %, Campylobacter jejuni 7 % and Salmonella spp. 4 %. Socioeconomic characteristics were not helpful in differentiating disease due to specific enteropathogens. Ninety per cent cases caused by viruses only affected children under three years of age. Rotavirus gastroenteritis had a marked seasonal pattern (90 % cases in December-February). Among infants < or = 6 months of age rotavirus was less frequent as cause of diarrhea in breast-fed infants than in bottle-fed. Macroscopic blood in stools was reported almost exclusively among patients with a bacterial infection. In 96 % of all cases of diarrhea there was no dehydration, in 2 % it was mild, in 2 % moderate and none severe. Ten of the seventeen cases (59 %) of moderate dehydration were caused by rotavirus. Six percent of all children were hospitalised.

CONCLUSIONS

Rotavirus was significantly more associated with the need for intravenous fluid therapy and hospitalisation than episodes negative for rotavirus. Rotavirus accounted for 3 % of hospitalisations in infants aged 1 month-2 years.