Epidemiology of rotavirus diarrhea among children less than 5 years hospitalized with acute gastroenteritis prior to rotavirus vaccine introduction in India

Effect of rotavirus vaccination on the burden of rotavirus disease and associated antibiotic use in India: A dynamic agent-based simulation analysis

BACKGROUND

Rotavirus is a leading cause of diarrhea in infants and young children in many low- and middle-income countries. India launched a childhood immunization program for rotavirus in 2016, starting with four states and expanding it to cover all states by 2019. The objective of this study was to estimate the effects of the rotavirus vaccination program in India on disease burden and antibiotic misuse.

METHODS

We built a dynamic agent-based model of rotavirus progression in children under five within each district in India. Simulations were run for various scenarios of vaccination coverage in the context of India's Universal Immunization Programme. Population data were obtained from the National Family Household Surveys and used to calibrate the models. Disease parameters were obtained from published studies. We estimated past and projected future reduction of disease burden and antibiotic misuse due to full vaccination nationwide, by state, and by wealth quintile.

RESULTS

We estimate that rotavirus vaccination in India has reduced the prevalence of rotavirus cases by 33.7% (prediction interval: 30.7-36.0%), total antibiotic misuse due to rotavirus by 21.8% (18.6-25.1%), and total deaths due to rotavirus by 38.3% (31.3-44.4%) for children under five. We estimate total antibiotic misuse due to rotavirus infection to be 7.6% (7.5-7.9%) of total antibiotic consumption in this demographic versus 9.6% (9.4-9.9%) in the absence of vaccination. We project rotaviral prevalence to drop to below one case for every 100,000 individuals in those below five if vaccination coverage is increased by 50.3% (45.2-58.5%) to 68.1% (63.1-76.4) nationwide.

CONCLUSION

Universal coverage of childhood rotavirus vaccination can substantially reduce inappropriate antibiotic use in India.

Role of rotavirus vaccine in reducing diarrheal episodes in infants visiting private primary health care clinics in Karachi, Pakistan: A mixed-methods study

BACKGROUND

Rotavirus (RV) induced diarrhea led to hospitalization and mortality prior to the introduction of the rotavirus vaccine (RVV). The estimated RVV coverage was 86% in children less than one year of age in Pakistan.

OBJECTIVES

To determine the difference in the number of diarrheal episodes among children who received and who did not receive RVV, along with the parental and physician's perspectives on the barriers toward RV immunization in children aged less than 1 year in Karachi, Pakistan.

METHODS

A mixed-methods study design was conducted in three Primary Healthcare (PHC) private clinics located in different districts of Karachi, Pakistan. Data for RVV status and diarrheal episodes were collected, from medical records in June 2020 for children born between October 2019 to March 2020. Three In-depth Interviews (IDIs) with physicians and three focus group discussions (FGDs) with mothers were conducted for information on awareness and approach towards diarrhea, knowledge, and acceptance of RVV, and barriers towards RV immunization.

RESULTS

A total of 430 infants visited the three PHC centres coded as A (n = 144), B (n = 146), and C (n = 140). The mean age of infants was 2.6 ± 0.2 months, 49.5 % were males and 87 (20.2 %) were partial/not vaccinated for RV. Reported diarrheal episodes were 104 (24.2 %), and of these 76 (73.1 %) were partially or not vaccinated, and 83 (79.8 %) were stunted. Recorded diarrhea was significantly associated with partial/not vaccinated status (p < 0.001), stunting (p < 0.001), and by PHC centre location (p < 0.001). PHC-C had the lowest percentage of reported diarrhea, stunting, and non/partially vaccinated status. Qualitative study (FGDs) showed that mothers had lack of awareness and knowledge on the prevention of diarrhea by RVV. Physicians' IDIs pointed towards a lack of sufficient training on RVV.

CONCLUSION

Diarrheal episodes in infants were associated with partial or unvaccinated for RVV, low nutritional status, and areas of residence. Low levels of knowledge and awareness in caretakers and lack of training for RVV in PHC physicians were perceived as barriers in controlling diarrheal diseases.

Enablers and barriers to rotavirus vaccine coverage in Assam, India- A qualitative study

Background

Estimates suggest that 78,000 children died due to rotavirus gastroenteritis annually between 2011 and 2013 in India. The north eastern state of Assam reported 38.4% pediatric diarrheal admissions testing positive for rotavirus. Rotavirus vaccine (RVV) was introduced in Assam in 2017 following which the National Family Health Survey-5 (NFHS-5) (2019) revealed low RVV coverage in Assam with wide variation between the districts. the current study was conceptualized and undertaken to capture the enablers and barriers to RVV coverage in Assam.

Methods

Qualitative study conducted in 5 randomly selected districts in Assam. Participants (key informants) were recruited by purposive sampling at each level of the health system including healthcare officials, service providers and caregivers based on availability. Thirty-five in-depth interviews (IDIs) and five focus group discussions (FGDs) were conducted. Interviews were tape recorded and transcribed. Data was coded and analyzed using the thematic framework approach.

Results

Findings from the qualitative data collection were collated and analyzed under 7 identified themes. Difficult terrain, limited service provider availability and no catch-up training for new recruits were some of the barriers to RVV coverage. In contrast, Information, Education & Communication (IEC) in vernacular language, RVV safety profile, development partner support and adequate RVV supply were identified as some of the enablers of RVV coverage.

Conclusion

Few broad recommendations to overcome identified barriers include comprehensive inter-sectoral coordination, regular monitoring and frequent refresher training sessions. There is a need for a future study utilizing existing coverage data and larger sample size to triangulate the findings of this study.

Risk Factors of Convulsions in Children With Rotavirus Gastroenteritis and Construction of a Nomogram Prediction Model

OBJECTIVE

This study aims to investigate and analyze the risk factors of convulsions in children with rotavirus gastroenteritis and to construct a nomogram prediction model.

METHODS

A retrospective analysis was performed on 940 cases of pediatric patients with rotavirus gastroenteritis treated in our hospital from December 2017 to December 2022. Based on whether convulsions occurred during hospitalization, patients were divided into the convulsion group (n = 135) and the convulsion-free group (n = 805). Clinical information of patients in both groups was collected, logistic regression analysis was carried out to analyze the convulsion risk factors pertaining to children with rotavirus gastroenteritis, and a nomogram prediction model was constructed.

RESULTS

The univariate analysis revealed that fever, frequency of diarrhea, white blood cell count, blood calcium level, blood glucose level, CO 2 CP, creatine kinase myocardial band (CK-MB), and blood pH value were all factors that display statistically significant differences at the level of P = 0.05. Then, logistic regression analysis was carried out, taking the occurrence of such convulsions as the dependent variable and the aforementioned factors as independent variables. The results show that fever, frequency of diarrhea, blood calcium, CO 2 CP, and CK-MB were the independent risk factors ( P < 0.05), whereas the area under the receiver operating characteristic curve (area under the curve) of the constructed nomogram prediction model based on these factors was 0.842 (95% confidence interval, 0.821-0.914).

CONCLUSIONS

Frequency of diarrhea, blood calcium, CO 2 CP, and CK-MB are independent risk factors for the occurrence of convulsions in children with rotavirus gastroenteritis. The nomogram prediction model constructed based on these risk factors provides guidance and value in effectively preventing and controlling convulsions in children with rotavirus gastroenteritis.

Potential impact of rotavirus vaccination on reduction of childhood diarrheal disease in India: An analysis of National Family Health Survey-5

Rotavirus is one of the leading causes of diarrhea in infants and young children worldwide. In this study, we investigated the impact of rotavirus vaccination on the prevalence of diarrheal disease among children under five years of age in India. Research on the impact of the rotavirus vaccine on reducing diarrheal disease is therefore important in contributing to the growing body of evidence on the effectiveness of this intervention in improving child health outcomes. We adopted multivariate logistic regression and propensity score matching analysis to examine the association between diarrhea and the rotavirus vaccine. The bivariate analysis finding shows that the prevalence of diarrhea was remarkably higher (9.1%) among children who had not received rotavirus and the prevalence was 7.5%, 7.5%, and 7.2% among children who received one dose, two doses, and three rotavirus doses (all) respectively. The result of multivariate logistic regression shows that children who received all three doses of the rotavirus vaccine were 16% less likely to experience diarrhea compared to those who did not receive any rotavirus vaccine. Our analysis also found that the prevalence of diarrhea decreased significantly in the years following the introduction of the vaccine. The results of this study suggest that the rotavirus vaccine has a significant impact on reducing childhood diarrheal disease in India. These results have the potential to inform policy decisions and enable healthcare professionals to concert their efforts in reducing the diarrheal disease burden and its timely prevention in children. The study will also contribute to the existing literature on the impact of rotavirus vaccination in reducing the prevalence of diarrhea among children in India.

Enteric and non-enteric adenoviruses in children with acute gastroenteritis in Western India

Human adenoviruses (HAdVs) are the viral agents responsible for a wide spectrum of acute and chronic diseases. HAdVs are the most important etiological agents of acute gastroenteritis (AGE) and are identified as the major contributor to the deaths of diarrheal children globally. The significant rise in HAdV infections in rotavirus-vaccinated children documented in multiple studies demands continuous monitoring of HAdV strains. After the inclusion of rotavirus vaccines in the immunization schedule of India, public health research regarding prevalence, etiology, and risk factors is highly necessary for evidence-based policies and their implementation to sustain diarrhea prevention programs. In the present study, children admitted for AGE between 2013 and 2016 in seven different hospitals in Maharashtra and Gujrat states of Western India were subjected for investigation. HAdVs were found in 5.2% of the fecal specimens with the dominance of species-F (52.4%) strains, followed by the occurrence of non-enteric adenoviruses of species A (17.4%), C (11.4%), B (8.2%), and D (3.2%). The species-F strains were predominant in Ahmadabad (78.5%), Mumbai (61.5%), and Surat (57.1%) cities, followed by species-A strains. In Pune city, species B strains were detected in all HAdV patients, with none of the species A strains. Clinically, patients infected with enteric and non-enteric HAdV strains were indistinguishable. However, a high viral load was observed in species-F specimens as compared to non-species-F. The present study on fecal specimens collected in the pre-rotavirus vaccination era from hospitalized AGE patients will be important for future comparative analysis to know the exact impact of vaccination in children of Western India.

Diagnostic accuracy of rotavirus antigen tests in children: A systematic review and meta-analysis

OBJECTIVES

Rotavirus infection is the leading cause of acute gastroenteritis (AGE) in children. Children with rotavirus infection may have symptoms such as diarrhoea or vomiting. Diarrheal diseases caused by rotavirus and other enteric pathogens cannot be differentiated on the basis of clinical symptoms. Therefore, diagnostic testing is essential to confirm a diagnosis of rotavirus infection. The aim of the meta-analysis is to evaluate the diagnostic accuracy of immunochromatographic rotavirus antigen tests in children.

METHODS

We searched the PubMed, Embase, Cochrane Library and Google Scholar databases for studies evaluating the diagnostic accuracy of antigen tests for rotavirus in children. We included studies that provided sufficient data to construct a 2 × 2 table on a per patient basis. The overall sensitivity and specificity of the antigen tests were determined using a bivariate random-effects model.

RESULTS

In total, 12 studies with 4407 participants were included in the study. The meta-analysis yielded a pooled sensitivity of 89.2% (95% confidence interval [CI]: 77.4%-95.3%) and pooled specificity of 93.2% (95% CI: 83.8%-97.3%). A subgroup analysis of such tests in children aged ≤5 years yielded a pooled sensitivity of 87.1% and pooled specificity of 91.8%. Another subgroup analysis of high-quality studies involving 820 participants yielded a pooled sensitivity of 92.3% and pooled specificity of 95.2%.

CONCLUSIONS

Rotavirus antigen tests have high sensitivity for the diagnosis of rotavirus infection in children with AGE. In addition, such tests may be effective for the identification and clinical management of rotavirus infection in children and the prevention of disease progression.

Evaluation of Activity of Zinc Oxide Nanoparticles on Human Rotavirus and Multi-Drug Resistant Acinetobacter Baumannii

BACKGROUND

Rotaviruses are the cause of acute gastroenteritis and severe diarrheal diseases in children worldwide. Children under the age of five are more susceptible to rotavirus infections. Due to such as the lack of effective drugs and supportive therapy only, the development of new antiviral agents against rotaviruses is required. Multi-drug-resistant Acinetobacter baumannii is also one of the most challenging Gram-negative bacteria to control and treat due to its antibiotic resistance, particularly in intensive care units.

OBJECTIVE

This study aimed to investigate the activity of zinc oxide nanoparticles against human rotavirus and multi-drug resistant Acinetobacter baumannii.

METHODS

The standard 50% tissue culture infectious dose method and the real-time polymerase chain reaction assay were used to investigate the effects of zinc oxide nanoparticles on rotaviruses. The well diffusion and the minimum inhibitory concentration method were used to assess the antibacterial activity of zinc oxide nanoparticles against Acinetobacter baumannii.

RESULTS

300 μg/ml of zinc oxide nanoparticles demonstrated the highest anti-rotavirus effects, resulting in a 3.16 logarithmic decrease in virus infectious titer, and a four-unit increase in the cycle threshold value of the real-time polymerase chain reaction assay compared to the untreated control (P value <0.001 and P value = 0.005, respectively). The diameter of the inhibition zone of zinc oxide nanoparticles solution against Acinetobacter baumannii was 17 mm. The minimum inhibitory concentration results of the zinc oxide nanoparticles solution against Acinetobacter baumannii was 1.56 mg/ml.

CONCLUSION

Our findings showed that zinc oxide nanoparticles could be considered a promising antimicrobial compound.

Isolation, Propagation and Genotyping of Human Rotaviruses Circulating among Children with Gastroenteritis in Two Egyptian University Hospitals

Simple Summary

Group A rotaviruses are the most common cause of acute gastroenteritis affecting Egyptian children under the age of five, with symptoms ranging from asymptomatic infection to severe dehydration or death. In the present work, diarrheal samples from Egyptian children admitted to gastrointestinal pediatric wards of two main governmental hospitals were collected and molecularly analyzed for Group A rotavirus. Our findings revealed that rotaviruses accounted for more than one-sixth of all cases under study, peaking in the winter. G1P[8] was the most prevalent rotavirus genotype in this study. The two cell lines used in our work coherently isolated and propagated rotavirus strains. Continuous rotavirus detection and genome sequencing of the successfully isolated strains will be recommended in the future in order to support the control of such viruses, and tackle the problem in Egypt.

Abstract

The most prevalent cause of infectious neonatal diarrhea is Group A rotavirus (RVA). Unfortunately, there is a dearth of data on the incidence of rotavirus-associated infections among Egyptian children. The present study aimed to isolate, propagate, and genotype human rotaviruses circulating among Egyptian children with acute gastroenteritis admitted to two main university pediatric hospitals, Abo El-Reesh and El-Demerdash, over two consecutive winters, 2018–2020. Diarrheal samples (n = 230) were screened for Group A rotavirus RNA using RT-PCR assay. In positive samples (n = 34), multiplex semi-nested PCR was utilized to determine G and P genotypes. Thirty-four (14.8%) of the collected samples tested positive. The genotype distribution revealed that G1P[8] was the predominant rotavirus genotype throughout the current study. All rotavirus-positive fecal samples were passaged twice on human colorectal adenocarcinoma cell line (Caco-2) and rhesus monkey kidney epithelial cell line (MA104). Both cell lines could successfully isolate 14.7% (n = 5 out of 34) of the identified strains; however, Caco-2 cell line was shown to be more efficient than MA104 in promoting the propagation of human rotaviruses identified in Egyptian children’s feces.

Impact of Vaccination on Rotavirus Genotype Diversity: A Nearly Two-Decade-Long Epidemiological Study before and after Rotavirus Vaccine Introduction in Sicily, Italy

Sicily was the first Italian region to introduce rotavirus (RV) vaccination with the monovalent G1P[8] vaccine Rotarix® in May 2012. In this study, the seasonal distribution and molecular characterization of RV strains detected over 19 years were compared to understand the effect of Rotarix® on the evolutionary dynamics of human RVs. A total of 7846 stool samples collected from children < 5 years of age, hospitalized with acute gastroenteritis, were tested for RV detection and genotyping. Since 2013, vaccine coverage has progressively increased, while the RV prevalence decreased from 36.1% to 13.3% with a loss of seasonality. The local distribution of RV genotypes changed over the time possibly due to vaccine introduction, with a drastic reduction in G1P[8] strains replaced by common and novel emerging RV strains, such as equine-like G3P[8] in the 2018−2019 season. Comparison of VP7 and VP4 amino acid (aa) sequences with the cognate genes of Rotarix® and RotaTeq® vaccine strains showed specific aa changes in the antigenic epitopes of VP7 and of the VP8* portion of VP4 of the Italian RV strains. Molecular epidemiological surveillance data are required to monitor the emergence of novel RV strains and ascertain if these strains may affect the efficacy of RV vaccines.

The Current Epidemiology of Rotavirus Infection in Children Less than 5 Years of Age after Introduction of RV Vaccine in India

Rotavirus is a major cause of severe acute gastroenteritis in infants and young children worldwide. It is responsible for 40% of childhood hospitalization. It has been estimated that about 23% of diarrhoeal death occurs due to the rotavirus infection in India. To study the epidemiology of rotavirus infection in children less than 5 years of age at a tertiary care teaching hospital. A total of 240 stool samples were collected from children <5 years of age suffering from acute diarrhea at a tertiary health care referral hospital in Western Uttar Pradesh, India. Rotavirus antigen was detected in stool by Enzyme immunoassay (EIA) which utilizes monoclonal antibodies directed against VP6 antigen. Molecular genotyping was done by nested multiplex PCR. The rotavirus antigen positivity rate was found to be 14.58% in this study. There was male preponderance and the male: female ratio was 1.5:1. Rotavirus diarrhoea was reported predominantly (42.85 %) in the age group of 13 to 24 months. The most common circulating G/P genotype strain was G9P[4] accounting for 36% of cases. Rotavirus remains a major cause of diarrhoea in children <5 years of age in Uttar Pradesh. However, the positivity rate has decreased after introduction of rotavirus vaccine into the Universal immunization program (UIP) in UP.

Clinical Profile and Characterization of Rotavirus Strains in Under-Five Children with Diarrhea: A Hospital-Based Study from Eastern Odisha, India

Objective Diarrheal diseases are one of the most common causes of hospitalization in children under five. Rotavirus is the most common cause of acute diarrhea in younger children, and the prevalence decreases rapidly with increasing age. The objective of the study was to estimate the burden of rotavirus infection in acute gastroenteritis among under-five children admitted to a tertiary care hospital in eastern Odisha, for the clinical profile and identity of the prevalent strains.

Methods This was a prospective observational study linked to the National Rotavirus Surveillance Network (NRSN), where 720 under-five children with diarrhea were enrolled. In total, 675 stool samples of eligible candidates were sent for rotavirus isolation, and identification of strains was done by identifying VP7 (G-type) and VP4 (P-type) genes by reverse transcription polymerase chain reaction.

Results Categorical variables were presented as frequency and percentage, and continuous variables were expressed as mean ± standard deviation. Rotavirus was detected in 256 (37.92%) samples. Males outnumbered females. The most common affected age group was 7 to 12 months, followed by 13 to 18 months. G3P[8] was the most prevalent strain in this study.

Conclusion Children between the age of 7 and 18 months were most vulnerable to rotavirus infection. The most prevalent strain varies from one region to another and continuous surveillance is needed.

Genotypic characterization of group A rotavirus in children < 5 years of age at tertiary care hospital in North India

PURPOSE

This study was undertaken to find out the positivity of rotavirus associated diarrhoea in children <5 years of age in Meerut district and to determine the genomic diversity of the circulating rotavirus strains in this geographical area.

METHODS

A cross-sectional study was conducted in a tertiary care hospital for a period of one year. A total of 240 stool samples were collected from children suffering from acute diarrhoea and subjected for rotavirus antigen detection by enzyme immunoassay (EIA). The EIA-positive samples were further genotyped to determine the G and P types using semi nested multiplex reverse transcriptase-polymerase chain reaction (RT-PCR). Demographic and clinical parameters were recorded in a pre-designed proforma.

RESULTS

The rotavirus antigen positivity rate was 14.58% in Meerut district. There was male predominance and highest positivity rate was seen in children 13-24 months of age, in winter months and majority of cases belonged to moderate degree of severity. A total of 64% children in the study area were vaccinated and positivity was low in the vaccine group. G9P[4] was the predominant genotype followed by G3P[8]. Uncommon strains G12P[6] and G12P[8] were also reported as circulating genotypes in this study.

CONCLUSIONS

The positivity rate of rotavirus associated diarrhoea has reduced in Meerut district post vaccination. G9P[4] was the most common circulating RV genotype in Meerut. Our study highlights the importance of including the emerging rotavirus strains in future multivalent RV vaccines to make the vaccines regionally more specific.

Prevalence and genetic diversity of gastroenteritis viruses in hospitalized children < 5 years of age in Maharashtra state, Western India, 2017-2019

Four gastroenteritis viruses were responsible for 54% of the acute gastroenteritis (AGE) cases in children hospitalized between May 2017 and December 2019 in Pune city of Maharashtra state, Western India. The majority (79%) of the children were <2 years of age. The prevalence of Rotavirus A (RVA) was 30.5% followed by 14.3% for norovirus, 8.4% for adenovirus, and 5.5% for astrovirus. The severity of the disease was highest in patients with coinfections compared with the patients with a single infection or negative for all (p = 0.024). Genotyping analysis showed that the majority of the RVA-positive samples (66%) could be typed as G3P[8], 63.6% of the norovirus as GII.4 Sydney [P16], 44% of the adenovirus as type 41%, and 56.2% of the astrovirus as astrovirus type 1. The almost equivalent prevalence of rotavirus and nonrotaviruses and acute gastroenteritis (AGE) cases without known etiology in around 46% of the cases was noted in the present study. Our data highlight that after the recent inclusion of rotavirus vaccines as a part of the National Immunization schedule in India, conducting extensive AGE surveillance in children should include nonrotaviruses such as norovirus.

The Short-term Effects of Temperature on Infectious Diarrhea among Children under 5 Years Old in Jiangsu, China: A Time-series Study (2015-2019)

The association between meteorological factors and infectious diarrhea has been widely studied in many countries. However, investigation among children under 5 years old in Jiangsu, China remains quite limited. Data including infectious diarrhea cases among children under five years old and daily meteorological indexes in Jiangsu, China from 2015 to 2019 were collected. The lag-effects up to 21 days of daily maximum temperature (Tmax) on infectious diarrhea were explored using a quasi-Poisson regression with a distributed lag non-linear model (DLNM) approach. The cases number of infectious diarrhea was significantly associated with seasonal variation of meteorological factors, and the burden of disease mainly occurred among children aged 0–2 years old. Moreover, when the reference value was set at 16.7°C, Tmax had a significant lag-effect on cases of infectious diarrhea among children under 5 years old in Jiangsu Province, which was increased remarkably in cold weather with the highest risk at 8°C. The results of DLNM analysis implicated that the lag-effect of Tmax varied among the 13 cities in Jiangsu and had significant differences in 8 cities. The highest risk of Tmax was presented at 5 lag days in Huaian with a maximum RR of 1.18 (95% CI: 1.09, 1.29). Suzhou which had the highest number of diarrhea cases (15830 cases), had a maximum RR of 1.04 (95% CI:1.03, 1.05) on lag 15 days. Tmax is a considerable indicator to predict the epidemic of infectious diarrhea among 13 cities in Jiangsu, which reminds us that in cold seasons, more preventive strategies and measures should be done to prevent infectious diarrhea.