The burden of Rotavirus gastroenteritis among hospitalized pediatric patients in a tertiary referral hospital in Jeddah

Rotavirus and adenovirus in children evaluated for viral gastroenteritis at a single healthcare center in the Eastern Province of Saudi Arabia: A perspective of two decades

BACKGROUND

The aim of this study was to determine the distribution of rotavirus and adenovirus in pediatric patients evaluated for viral gastroenteritis in a hospital in the Eastern Province of Saudi Arabia for 22 years.

MATERIALS AND METHODS

This was a retrospective study based in a secondary healthcare center in Saudi Arabia. Laboratory and demographic data were collected from hospital records for all pediatric patients (up to 14 years old) evaluated for viral gastroenteritis by rotavirus/adenovirus antigen detection kit from January 2000 to December 2022. Data were analyzed utilizing SPSS version 28.0. Categorical data were presented as frequency and percentages, whereas mean and standard deviations were computed for continuous variables. Chi-square test and t-test were used to determine statistical significance.

RESULTS

The overall yields of antigen detection were 13.6% for rotavirus and 2.6% for adenovirus. Coinfection with both viruses was documented in 0.5% of the study population. Rotavirus was persistently detected in the past two decades with varying frequency, but the detection of adenovirus showed intervals of at least three consecutive years of zero confirmed cases. Before 2013, when the rotavirus vaccine was introduced in Saudi Arabia, rotavirus was much more prevalent than adenovirus (30% compared to 3.8% in 2010), but they became equally prevalent a decade after the introduction of the vaccine. Rotavirus gastroenteritis showed three different peaks in the year, in March, July, and December. Each peak was followed by a gradual decrease in prevalence before the next peak. Adenovirus, in contrast, was detected consistently around the year at rates between 2% and 5%.

CONCLUSION

Rotavirus and adenovirus gastroenteritis have changed in prevalence in the past two decades. We found distinct seasonal patterns associated with rotavirus and adenovirus gastroenteritis. The utilization of virological testing for pediatric gastroenteritis with syndromic testing panels is to be encouraged to improve the knowledge of the true prevalence of enteric viruses.

Molecular epidemiology, genetic diversity, and vaccine availability of viral acute gastroenteritis in the middle East and North Africa (MENA) region

Acute gastroenteritis is the cause of considerable mortality and morbidity worldwide, particularly among children under five years in underdeveloped countries. Most acute gastroenteritis (AGE) cases are attributed to viral etiologies, including rotavirus, norovirus, adenovirus, astrovirus, and sapovirus. This paper aimed to determine the prevalence rate of different viral etiologies of AGE in the Middle East and North Africa (MENA) region. Moreover, this paper explored rotavirus phylogenetic relatedness, compared VP7 and VP4 antigenic regions of rotavirus with vaccine strains, and explored the availability of vaccines in the MENA region. The literature search identified 160 studies from 18 countries from 1980 to 2019. The overall prevalence of rotavirus, norovirus, adenovirus, astrovirus, and sapovirus were 29.8 %, 13.9 %, 6.3 %, 3.5 %, and 3.2 % of tested samples, respectively. The most common rotavirus genotype combinations in the MENA region were G1P[8], G9P[9], and G2P[4], whereas GII.4 was the predominant norovirus genotype all of which were reported in almost all the studies with genotyping data. The comparison of VP7 and VP4 between circulating rotavirus in the MENA region and vaccine strains has revealed discrete divergent regions, including the neutralizing epitopes. Rotavirus vaccine was introduced to most of the countries of the MENA region; however, only a few studies have assessed the effectiveness of vaccine introduction. This paper provides a comprehensive update on the prevalence of the different viral agents of AGE in the MENA region.

Systematic review of the rotavirus infection burden in the WHO-EMRO region

Rotavirus gastroenteritis imposes a heavy burden on low- and middle-income countries. The World Health Organization defines the Eastern Mediterranean region (WHO-EMRO) as a diverse area in terms of socioeconomic status and health indicators. Rotavirus vaccination has been introduced, at least partially, in 19 out of the 22 EM countries; however, vaccine coverage remains low, and data on rotavirus disease burden is scarce.Available data on rotavirus prevalence, seasonality, vaccination status, and genotype evolution was systematically compiled following a literature review that identified 165 relevant WHO-EMRO epidemiology studies published between 1990 and 2017.Although the infectious agents responsible for acute gastroenteritis vary over time, rotavirus remained the leading cause of acute gastroenteritis in children, as seen in 76.3% of reviewed publications. Younger children (<2 years old) were at higher risk and thus increased vaccination coverage and surveillance systems are required to reduce the rotavirus gastroenteritis burden in WHO-EMRO countries.

Update on the epidemiology of rotavirus in the Middle East and North Africa

Rotavirus (RV) is the leading cause of severe acute gastroenteritis (AGE) worldwide. Consequently, we conducted a systematic literature review on articles studying RV in the 25 countries of the MENA region during the past 15years (2000-2015). The methods and reporting were set according to the 2015 preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) and based on the elements from the international prospective register of systematic reviews (PROSPERO). Our literature search identified 169 studies meeting our predefined inclusion criteria. Studies reporting on RV were conducted in 19 out of the 24 countries of the MENA region. The largest number of studies was reported in Turkey (n=32), Iran (n=31), Saudi Arabia (n=19) and Egypt (n=17). The majority of studies reporting on RV gastroenteritis rates were clinical observational studies. In 115 studies out of 169, RV was reported among in-patients whereas 35 studies reported RV among outpatients. The predominantly reported RV genotype in the region was G1[P8] followed by G2[P4] and G9[P8]. The majority of studies (n=108) were conducted among children less than 5years of age whereas the remaining studies reported on AGE among other age groups and rarely adults. In MENA countries, RV infection was reported all year round with peaks described in cold as well as hot months. This systematic review provides a current update on the epidemiology of RV-associated gastroenteritis in countries of the MENA region and draws attention to the major gaps existing in the continuous monitoring of RV.

Is rotavirus still a major cause for diarrheal illness in hospitalized pediatric patients after rotavirus vaccine introduction in the Saudi national immunization program?

Previous studies in Jeddah, western Saudi Arabia, showed rotavirus (RV) prevalence around 40% in pediatric inpatients with gastroenteritis (GE) with a maximum level during cooler months. Currently, there are no data on impact of rotavirus vaccine (RVV) on RV-GE in Saudi Arabia. Therefore, this study was conducted to assess impact of RVV on incidence and severity of RV-GE in hospitalized pediatric patients; 3 years after introduction of RVV in Saudi immunization program (SIP) in January, 2013.This cross-sectional observational study included GE cases under 5 years of age admitted to 2 tertiary hospitals, in Jeddah, from October to December, 2015. All included GE-cases had RV antigen detection in stool by immunochromatographic assay, complete data collection including RVV status and severity assessment (Vesikari score) in initial admission.During study period, a total of 359 GE cases in children under 5 years of age were hospitalized with 14 (3.9%) RV-GE confirmed cases. Mean age of RV-GE patients was 13.10 ± 5.70 months. All RV cases had severe GE and 1 case received RVV. Among other 345 GE cases, 35.7% did not receive RVV and 46.1% had severe GE. Severe GE (Vesikari score > 11) was more significantly identified among RV-GE cases than in other all-cause GE (P < .001). During same period of this study in 2012, 369 RV-GE out of 1193 total GE cases (31%) were hospitalized at 2 hospitals, so, number of hospitalized pediatric patients for all-cause and RV-GE in children under 5 years of age decreased significantly in 2015 RV season (compared to 2015 RV season, odds ratio for RV-GE in 2012: 11.04, 95% CI: 6.38-19.09).Logistic regression analysis of variables of this cross-sectional, hospital-based study in Jeddah, Saudi Arabia, 3 years after introduction of RVV in SIP, showed that among the studied variables, RVV was associated with remarkable reduction of hazard of all-cause and RV-GE in vaccinated and even in unvaccinated children under 5 years of age possibly by RVV herd effect. However, RV was still associated with severe GE-related hospitalizations in unvaccinated children against RV who were younger than 2 years and particularly in the 1st year of life, indicating need for more optimum rate of RVV coverage. Hopefully, further improvement in RVV coverage rate may make RV-GE a disease of the past in Saudi children.

Epidemiology of group A rotavirus infection after the introduction of monovalent vaccine in the National Immunization Program of Saudi Arabia

This study aimed to investigate the prevalence of group A rotavirus (RVA) gastroenteritis and the distribution of the RVA genotypes as well as to determine a possible change in the age of occurrence of the RVA infection in the first 2 years after Rotarix® vaccine introduction in Saudi Arabia. This descriptive study included 850 hospitalized children <5 years of age with acute gastroenteritis (AG) between October 2013 and September 2015. Overall, 78 (9.2%) children were positive for RVA during the study period with a positivity rate ranging from 11.3% in the first year of the study to 6.8% in the second year. G1 (47.4%) was the predominant G type, followed by G2 (28.2%) and G9 (10.3%). The most common P type was P[8] (69.2%) followed by P[4] (25.6%). The decrease in the prevalence of G1P[8] from 51% to 37.1% was associated with an increase in the prevalence of G2P[4] from 21.6% to 33.3% during the 2-year study period. This study demonstrated a significant decrease in the prevalence of RVA-AG cases in the first 2-year period after vaccine introduction, especially in the age group between 1 and 12 months, and a reduction in the circulation of G1P[6]. The parallel rise and spread of G2P[4] in post-vaccination period might pose an impact to long-term vaccine efficacy. Continued surveillance studies in different Saudi regions are crucial to document the effectiveness of Rotarix® vaccine and evaluate the potential emergence of rare/novel RVA genotypes. J. Med. Virol. 89:429-434, 2017. © 2016 Wiley Periodicals, Inc.

Gastroenteritis attributable to rotavirus in hospitalized Saudi Arabian children in the period 2007-2008

Purpose

Rotavirus (RV) is a leading cause of severe gastroenteritis (GE) in children across the world. As there is a lack of epidemiological data for RV gastroenteritis (RVGE) in Saudi Arabia, this hospital-based study was designed to estimate the disease burden of RVGE and assess the prevalent RV types in Saudi children younger than 5 years of age.

Patients and methods

Children hospitalized for acute GE were enrolled at four pediatric referral hospitals in Saudi Arabia. The study was conducted from February 2007 to March 2008 and used the World Health Organization’s generic protocol for RVGE surveillance. The Vesikari severity scale was used to assess the severity of RVGE. Stool samples were tested for RV using an enzyme-linked immunosorbent assay. Samples were further typed by reverse transcriptase–polymerase chain reaction and hybridization assay for determining the G and P types.

Results

A total of 1,007 children were enrolled; the final analysis included 970 children, of whom 395 were RV positive, 568 were RV negative, and seven had unknown RV status. The proportion of RVGE among GE hospitalizations was 40.7% (95% confidence interval: 37.6–43.9). The highest percentage of RVGE hospitalizations (83.1%) was seen in children younger than 2 years of age. The highest proportion of RV among GE hospitalizations was in June 2007 with 57.1%. The most common RV types detected were G1P[8] (49.3%), G1G9P[8] (13.2%), and G9P[8] (9.6%). Before hospitalization, severe GE episodes occurred in 88.1% RV-positive and 79.6% RV-negative children. Overall, 94% children had recovered by the time they were discharged. Two children (one RV positive and one RV negative) died due to GE complications.

Conclusion

RVGE is responsible for a high proportion of hospitalizations in Saudi children younger than 5 years of age. Routine RV vaccination has therefore been introduced into the national immunization program and may help reduce the morbidity, mortality, and disease burden associated with RVGE in Saudi Arabia.