Hospitalisations for rotavirus gastroenteritis among children under five years of age in New South Wales

Surveillance of the Most Prevalent Medical Diseases among Pediatric Age Groups and Evaluation of the Control Measures Used At Tabuk Hospitals, Saudi Arabia

BACKGROUND

During the last decades, medical recordings has increased dramatically leading to more awareness of the diseases commonly affecting paediatric age groups opening a wide entrance to the prevention of possible complications and decrease its incidence.

AIM

This article aims to assess the prevalence of the commonly encountered paediatric medical diseases by affected system among admitted paediatric patients of different age groups in Tabuk and to identify their burden.

METHODS

This is a retrospective research studying disease pattern according to age, gender, nationality, admission status and length of stay.

RESULTS

Admissions due to respiratory system disorders were the most common among children under the age of six years (39.7%). Acute gastroenteritis was the most common disease leading to hospitalisation of children below the age of three years and cast a financial burden heavily on family and society.

CONCLUSIONS

Respiratory diseases and acute gastroenteritis constitute a significant burden of childhood illnesses in Tabuk City. Efforts are required to reduce the impact to achieve the Saudi ministry of health (SMOH) Goal. Even though Rota vaccine is added to the national Saudi program of vaccination schedule, other causes should be looked for, and preventive measures are important as a part of public education.

Rotavirus vaccine and health-care utilization for rotavirus gastroenteritis in Tsu City, Japan

Background

Rotavirus vaccines were introduced in Japan in November 2011. We evaluated the subsequent reduction of the health-care burden of rotavirus gastroenteritis.

Methods

We conducted active surveillance for rotavirus gastroenteritis among children under 5 years old before and after the vaccine introduction. We surveyed hospitalization rates for rotavirus gastroenteritis in children in Tsu City, Mie Prefecture, Japan, from 2007 to 2015 and surveyed the number of outpatient visits at a Tsu City clinic from 2010 to 2015. Stool samples were obtained for rotavirus testing and genotype investigation. We assessed rotavirus vaccine coverage for infants living in Tsu City.

Results

In the pre-vaccine years (2007–2011), hospitalization rates for rotavirus gastroenteritis in children under 5 years old were 5.5, 4.3, 3.1 and 3.9 cases per 1000 person-years, respectively. In the post-vaccine years (2011–2015), the rates were 3.0, 3.5, 0.8 and 0.6 cases per 1000 person-years, respectively. The hospitalization rate decreased significantly in the 2013–2014 and 2014–2015 seasons compared to the average of the seasons before vaccine introduction (P < 0.0001). In one pre-vaccine year (2010–2011), the number of outpatient visits due to the rotavirus infection was 66. In the post-vaccine years (2011–2015), the numbers for each season was 23, 23, 7 and 5, respectively. The most dominant rotavirus genotype shifted from G3P[8] to G1P[8] and to G2P[4]. The coverage of one dose of rotavirus vaccine in Tsu City was 56.5% in 2014.

Conclusion

After the vaccine introduction, the hospitalization rates and outpatient visits for rotavirus gastroenteritis greatly decreased.

Gastrointestinal pathogen distribution in symptomatic children in Sydney, Australia

There is limited information on the causes of paediatric diarrhoea in Sydney. This cross-sectional study used clinical and microbiological data to describe the clinical features and pathogens associated with gastrointestinal illnesses for children presenting to two major public hospitals in Sydney with diarrhoea, for the period January 2007-December 2010. Of 825 children who tested positive for an enteric pathogen, 430 medical records were reviewed. Adenovirus, norovirus and rotavirus were identified in 20.8%, 20.3% and 21.6% of reviewed cases, respectively. Younger children were more likely to have adenovirus and norovirus compared with rotavirus (P=0.001). More viruses were detected in winter than in the other three seasons (P=0.001). Rotavirus presented a distinct seasonal pattern with the lowest rates occurring in the warm months and peaking in the cooler months. Adenovirus showed a less consistent monthly trend, and norovirus detection increased in the cooler months (P=0.008). A decline in the number of rotavirus cases was observed after mid-2008. The majority of childhood diarrhoeal illnesses leading to hospital presentations in Sydney are caused by enteric viruses with most infections following clear seasonal patterns. However, a sustained decrease in the incidence of rotavirus infections has been observed over the study period.

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.

Efficacy of high-dose Lactobacillus rhamnosus GG in controlling acute watery diarrhea in Indian children: a randomized controlled trial

AIM

To evaluate the effective dose of Lactobacillus rhamnosus GG (LGG) as probiotic in acute watery diarrhea (AWD) in Indian children.

SETTING

Hospital-based study.

DESIGN

Randomized, controlled, blinded trial.

METHODS

All patients of AWD admitted over 1 year were included in the study. They were randomized into 3 groups to receive either only oral rehydration solution (ORS) (group A/control), ORS+LGG powder containing 10(10) colony forming units (CFU) (group B), or ORS+LGG powder containing 10(12) CFU (group C) twice daily for a minimum period of 7 days or until diarrhea stopped along with correction of dehydration. None of them received any other drug such as antibiotic or antidiarrheal medication. The duration and frequency of diarrhea and vomiting were studied. Data were analyzed by SPSS-10 software.

RESULTS

The study comprised of 559 patients, group A/controls (n=185), group B (n=188), and group C (n=186). All the groups were similar with respect to age, number of breastfed infants, presentation with dehydration, degree of protein energy malnutrition, and rotavirus infection. The frequency and duration of diarrhea, requirement for intravenous therapy, and hospital stay were significantly lower in both the intervention groups compared with the controls. There was no significant difference between the 2 intervention groups. No complication was observed from the doses of LGG used.

CONCLUSIONS

Both the doses of LGG (10(10) and 10(12) CFU) were equally effective to decrease the frequency and duration of diarrhea and reduction in hospital stay in patients of AWD.

The burden of rotavirus gastroenteritis in children presenting to a paediatric hospital

The aim of this study was to determine the burden, management and outcomes of rotavirus infection in young children presenting to a tertiary paediatric hospital in Sydney, Australia. All laboratory-confirmed cases of rotavirus in children aged <5 years were identified and medical records reviewed. In 2004, 80 children aged <5 years presented to the hospital with rotavirus gastroenteritis confirmed by stool testing. Infants aged <24 months comprised 75% of cases, with more males than females affected. Most children (86%) acquired rotavirus infection in the community, with a mean length of hospital admission of 2·3 days. There were eight cases of nosocomial infection at a rate of 3/10 000 admissions. The rates of intravenous fluid management (46%) and antibiotic use (28%) were high, reflecting the severity of disease presenting in a hospital setting. These data will help inform the assessment of the recently introduced rotavirus vaccination programme in Australia.

Seasonal variation in acute hospital admissions and emergency room presentations among children in the Australian Capital Territory

AIM

To examine seasonal variation in hospital use for five paediatric conditions of the Australian Capital Territory residents.

METHODS

Hospital admissions (1993-2004) and emergency room (ER) presentations (1999-2004) for asthma, croup, bronchiolitis, other respiratory conditions and diarrhoea of children aged <5 years were compared by month and season.

RESULTS

The five conditions comprised 14% of admissions and 24% of ER presentations of children aged <5 years. Bronchiolitis (both admissions and ER presentations) were the highest in the 0-1 year age group (>80%) and the other four conditions peaked at 1-2 years. Children aged 0-2 years contributed 66% of diarrhoea, 62% of croup and 44% of other respiratory admissions whereas ER presentations were higher for other respiratory conditions (57%) and lower for croup (47%). Boys showed higher rates of admissions and ER presentations for all conditions except diarrhoea. Strong seasonal associations were apparent. Incident rate ratios of admissions were significantly higher in autumn compared with summer for asthma and croup whereas bronchiolitis and other respiratory conditions admissions were the highest in winter. Diarrhoea admissions were the highest in spring. ER presentations of the five conditions also showed similar associations with season.

CONCLUSION

Hospital admissions and ER presentations of these five conditions showed strong seasonal patterns, knowledge of which could contribute to improved resource planning (staffing) to meet expected increases in demand for services and scheduling of elective admissions. These findings could be extended to develop a model for forecasting hospital use and to explore the causes of these diseases to ameliorate seasonal effects.

Climatic factors associated with hospitalizations for rotavirus diarrhoea in children under 5 years of age

This study compares the seasonality of rotavirus diarrhoeal hospital admissions and its relationship to climatic factors across three Australian cities. Weekly admission of rotavirus diarrhoea (1993-2003) in children aged <5 years and weekly average temperature and relative humidity for each city were modelled using a log-linear model with a cubic trend and season. Interactions were included to test for differences in the effect of temperature and humidity between seasons and between cities. Admissions of rotavirus diarrhoea peaked in winter and spring and were lowest in summer. Higher temperature and humidity in the previous week were associated with a decrease in rotavirus diarrhoeal admissions in three cities. The effects of both temperature and humidity on rotavirus admissions in Brisbane differed across seasons. Strategies to combat outbreaks of rotavirus diarrhoea should take climatic factors and seasonal effects into consideration to plan for the excess seasonal hospital admissions.

Disease burden and related medical costs of rotavirus infections in Taiwan

Background

The disease burden and associated medical costs of rotavirus infections in inpatient and outpatient sectors in Taiwan were examined in anticipation of the availability of new rotavirus vaccines.

Methods

The yearly national case number and medical costs for all for inpatients and outpatients with acute gastroenteritis (AGE) were extracted from the Bureau of National Health Insurance database in Taiwan according to ICD-9-CM codes. A retrospective study was also performed using records of children with AGE seen at three hospitals in Taiwan in 2001 to identify laboratory confirmed rotavirus infection cases. The annual incidence and related medical costs of AGE due to rotavirus infection were then estimated.

Results

Children <5 years old comprised 83.6% of inpatient and 62.0% of outpatient pediatric AGE cases in Taiwan in 2001. Rotavirus was the most common agent detected among AGE patients in this age group in the three hospitals, and was detected in 32.9% (221/672) of inpatient and 24% (23/96) of outpatient stool specimens tested for microbial etiologies. An estimated 277,400 to 624,892 cases of rotavirus infections sought medical care in Taiwan in 2001, equaling one in 2 to 5 children <5 years old required medical care due to rotavirus infection. The incidence of hospitalization due to rotavirus infections was 1,528–1,997/100,000 for children <5 years old. The total associated medical costs due to rotavirus infection were estimated at US $10–16 millions in Taiwan in 2001. Although the per-capita medical cost of rotavirus infection was lower in Taiwan than in the United States or Hong Kong, the personal economic burden was similar among the three places when normalized for gross national incomes per capita.

Conclusion

Infections caused by rotavirus constitute an important human and economic burden among young children in Taiwan. A safe and effective vaccine is urgently needed.

The burden of rotavirus-related illness among young children on the Australian health care system

OBJECTIVE

To provide estimates of the annual number and cost of hospital admissions, emergency department (ED) visits and general practitioner (GP) visits for rotavirus (RV) related acute gastroenteritis (AGE) in young children in Australia.

METHODS

Numbers of hospitalisations for AGE were determined from national hospital morbidity data from July 1998 to June 2003. The fraction of these hospitalisations that may be attributed to RV was estimated by direct linkage of hospital admissions and pathology data from hospitals in two regions of Australia and by a second indirect method using the seasonal variation of RV infection. Numbers of ED visits were estimated using statewide data from Victoria and New South Wales (NSW), and numbers of GP visits were estimated from representative sample data for GP visits. Costs of RV hospital admissions and ED visits were estimated from national hospital cost data.

RESULTS

RV continues to account for around 10,000 hospitalisations annually for children aged less than five in Australia at an average cost of 1890 dollars each. There are an additional 22,000 ED visits a year where the child is not subsequently hospitalised, each at a cost of 320 dollars, and approximately 115,000 visits to GPs by children in this age group for RV-AGE at a cost of 36.60 dollars each.

CONCLUSIONS

The annual cost of hospital admissions, ED visits and GP visits associated with RV infection in young children in Australia is approximately 30 million dollars.

IMPLICATIONS

Vaccination against RV disease in Australia may provide substantial savings to the health care system, depending on the cost and effectiveness of an immunisation program.

Rotavirus hospitalisation in New Zealand children under 3 years of age

OBJECTIVE

To describe the epidemiology of severe rotavirus gastroenteritis and to estimate the hospitalisation rates of this illness in New Zealand children under 3 years of age.

METHODS

Children under 3 years of age with acute diarrhoea admitted to 1 of 8 study hospitals between 1 May 1998 and 30 April 2000 were surveyed. Their socio-demographic, treatment and length-of-stay data were recorded and stool samples tested by a rotavirus-specific enzyme-linked immunoassay. National hospital discharge data for infectious diarrhoea (International Classification of Diseases, ninth revision, 003-009) were reviewed, allowing population-based estimates for rotavirus-related hospitalisation in New Zealand.

RESULTS

Of 2019 enrolled children, 1138 (56.4%) provided stools for testing, and of these 485 (42.6%) tested rotavirus positive. Rotavirus detection varied significantly by age (26.8% for 0 to 5 months, 42.5% for 6 to 11 months and 52.1% for children aged 12 to 35 months; P < 0.001), and by season (51.2% in winter/spring vs. 24.5% in summer/autumn; P < 0.001). While those infected with rotavirus were more likely to be dehydrated (50.6% vs. 37.4%; P < 0.001), their median hospital stay was similar (1.0 vs. 2.0 days; P = 0.09) to other children with acute gastroenteritis. The estimated national hospitalisation rate for rotavirus diarrhoea in children under 3 years, standardised for age and season, was 634 (95% CI 597, 672) per 100,000. In New Zealand, rotaviruses result in 1 in 52 children being hospitalised by 3 years of age.

CONCLUSIONS

Rotavirus diarrhoea is an important, potentially vaccine-preventable cause of hospitalisation in New Zealand children, especially during winter and spring seasons.

Isotonic is better than hypotonic saline for intravenous rehydration of children with gastroenteritis: a prospective randomised study

AIMS

To determine whether the risk of hyponatraemia in children with gastroenteritis receiving intravenous (IV) fluids is decreased by the use of 0.9% saline.

METHODS

A prospective randomised study was carried out in a tertiary paediatric hospital. A total of 102 children with gastroenteritis were randomised to receive either 0.9% saline + 2.5% dextrose (NS) or 0.45% saline + 2.5% dextrose (N/2) at a rate determined by their treating physician according to hospital guidelines and clinical judgement. Plasma electrolytes, osmolality, and plasma glucose were measured before (T(0)) and 4 hours after (T(4)) starting IV fluids, and subsequently if clinically indicated. Electrolytes and osmolality were measured in urine samples. Results were analysed according to whether children were hyponatraemic (plasma sodium <135 mmol/l) or normonatraemic at T(0).

RESULTS

At T(0), mean (SD) plasma sodium was 135 (3.3) mmol/l (range 124-142), with 37/102 (36%) hyponatraemic. At T(4), mean plasma sodium in children receiving N/2 remained unchanged in those initially hyponatraemic (n = 16), but fell 2.3 (2.2) mmol/l in the normonatraemic group. In contrast, among children receiving NS, mean plasma sodium was 2.4 (2.0) mmol/l higher in those hyponatraemic at baseline (n = 21) and unchanged in the initially normonatraemic children. In 16 children who were still receiving IV fluids at 24 hours, 3/8 receiving N/2 were hyponatraemic compared with 0/8 receiving NS. No child became hypernatraemic.

CONCLUSIONS

In gastroenteritis treated with intravenous fluids, normal saline is preferable to hypotonic saline because it protects against hyponatraemia without causing hypernatraemia.

Health risks of enteric viral infections in children

Children are at a greater risk of infections from serious enteric viral illness than adults for a number of reasons. Most important is the immune system, which is needed to control the infection processes. This difference can lead to more serious infections than in adults, who have fully developed immune systems. There are a number of significant physiological and behavioral differences between adults and children that place children at a greater risk of exposure and a greater risk of serious infection from enteric viruses. Although most enteric viruses cause mild or asymptomatic infections, they can cause a wide range of serious and life-threatening illnesses in children. The peak incidence of most enteric viral illnesses is in children <2yr of age, although all age groups of children are affected. Most of these infections are more serious and result in higher mortality in children than adults. The fetus is also affected by enterovirus and infectious hepatitis resulting in significant risk of fetal death or serious illness. In addition to the poliovirus vaccine, the only vaccine available is for hepatitis A virus (HAV). A vaccine for rotavirus has currently been withdrawn, pending review because of potential adverse effects in infants. No specific treatment is available for the other enteric viruses. Enteric viral infections are very common in childhood. Most children are infected with rotavirus during the first 2yr of life. The incidence of enteroviruses and the viral enteric viruses ranges from 10% to 40% in children and is largely dependent on age. On average, half or more of the infections are asymptomatic. The incidence of hepatitis A virus is much lower than the enteric diarrheal viruses. There is no current evidence for hepatitis E virus (HEV) acquisition in children in the U.S. Enteric viral diseases have a major impact on direct and indirect health care costs (i.e., lost wages) and amount to several billion dollars a year in the U.S. Total direct and indirect costs for nonhospitalized cases may run from $88/case for Norwalk virus to $1,193/case for enterovirus aseptic meningitis. Direct costs of hospitalization ran from $887/case for Norwalk virus to $86,899/case for hepatitis A. These costs are based on 1997-1999 data. Generally, attack rates during drinking water outbreaks are greater for children than adults. The exception appears to be hepatitis E virus where young adults are more affected. However, pregnant women suffer a high mortality, resulting in concurrent fetal death. Also, secondary attack rates are much higher among children, probably because of fewer sanitary habits among this age group. Overall, waterborne outbreaks of viral disease have a greater impact among children than adults. To better quantify the impact on children, the literature hould be further reviewed for case studies of waterborne outbreaks where data are available on the resulting illness by age group. The EPA and/or Centers for Disease Control should attempt to collect these data as future outbreaks are documented.

High antidiuretic hormone levels and hyponatremia in children with gastroenteritis

OBJECTIVES

Nonosmotic antidiuretic hormone (ADH) activity can cause severe hyponatremia during involuntary fluid administration. We looked for evidence of this before and during intravenous (IV) fluid administration in children treated for gastroenteritis.

METHODOLOGY

In this prospective observational study, plasma ADH, electrolytes, osmolality, and glucose were measured in 52 subjects before (T0) and 4 hours after (T4) starting 0.45% saline + 2.5% dextrose and subsequently when indicated. Hormonal markers of stress were measured at T0. Urine samples were collected to measure electrolytes and osmolality.

RESULTS

The nonosmotic stimuli of ADH secretion that we identified were vomiting (50 of 52), dehydration (median: 5%; range: 3-8%), hypoglycemia (2 of 52), and raised hormonal markers of stress (mean +/- SD: cortisol, 1094 +/- 589 nmol/L; reverse triiodothyronine, 792 +/- 293 pmol/L). At T0, half the children were hyponatremic (plasma sodium concentration of < 135 mmol/L; n = 27). The median plasma ADH concentration at T0 was significantly elevated (median: 7.4 pg/mL; range: < 1.9-85.6 pg/mL). ADH was high in both hyponatremic and normonatremic children and remained high at T4 in 33 of the 52 children, 22 of whom were concurrently hyponatremic. At T4, mean plasma sodium concentration was unchanged in the hyponatremic children but was 2.6 mmol/L (+/-2.0) lower in those who were initially normonatremic. Urine tonicity was high compared with 0.45% saline in 16 of 19 children at baseline and in 20 of 37 children after 3 to 12 hours of IV fluids.

CONCLUSIONS

Nonosmotic stimuli of ADH secretion are frequent in children with gastroenteritis. Their persistence during IV-fluid administration predisposes to dilutional hyponatremia. The use of hypotonic saline for deficit replacement needs to be reassessed.

Incidence and Burden of Rotavirus Gastroenteritis in Japan, as Estimated from a Prospective Sentinel Hospital Study

We assessed the burden of rotavirus infection-related disease, in terms of hospitalization and associated costs, at 3 sentinel hospitals in Akita prefecture, Japan. From January 2001 through December 2002, a total of 443 children <5 years of age were hospitalized for acute gastroenteritis. Of 422 stool specimens collected, 244 (58%) tested positive for rotavirus. Only 7.8% of the rotavirus disease-associated hospitalizations involved infants <6 months of age, whereas most cases of disease (39%) were reported in the second year of life, and 89% of cases had occurred by 36 months of age. The mean severity score for rotavirus gastroenteritis resulting in hospitalization was 16.5, according to the modified 20-point severity scoring system. The average associated direct medical cost was 136,000 yen (1236 US dollars) per case and was similar among the 3 hospitals. The estimated incidence of rotavirus disease-associated hospitalizations among children <5 years of age was 7.9-17.6 hospitalizations/1000 person-years, and the estimated cumulative incidence by 5 years of age was 6.6%. Thus, approximately 1 in 15 children will require hospitalization due to rotavirus diarrhea by their fifth year of life. In Japan, this would mean that 78,000 children <5 years of age would be hospitalized each year, resulting in a direct medical cost of 10 billion yen (96 US dollars million). The burden associated with rotavirus gastroenteritis in Japan is substantial and might be reduced through the introduction of vaccines.

2. Acute infectious diarrhoea and dehydration in children

Gastroenteritis in children is still a common reason for consulting a general practitioner and for hospital admission. Rotavirus is the most common cause of gastroenteritis in children and accounts for half of all hospital admissions for severe acute infectious diarrhoea. Most children with gastroenteritis do not develop dehydration and can be treated at home. Children with mild to moderate dehydration should be treated with low osmolarity oral rehydration solutions, and those with severe dehydration or shock need to be admitted for administration of intravenous fluids. Lactose-free feeds should not be routinely used after acute gastroenteritis, but there is some evidence that a lactose-free diet may reduce the duration of diarrhoea. Antimotility drugs are rarely indicated in children with gastroenteritis, as the potential risks outweigh the benefits. The development of a rotavirus vaccine would provide huge public health benefits and cost savings. Other preventive strategies include educating people about personal and food hygiene and encouraging breastfeeding.

Diarrhea morbidity and mortality in Mexican children: impact of rotavirus disease

AIM

To analyze changes in prevalence and seasonality of diarrhea morbidity and mortality and to evaluate the impact of rotavirus disease among Mexican children younger than 5 years old.

METHODS

Diarrhea surveillance was performed from 1990 to 2002. Rotavirus testing was performed on stool specimens from 1996 to 2002. Data were obtained from different surveillance systems considering a nationwide representation in Mexico. Diarrhea morbidity and mortality rates were analyzed against time to determine trends or seasonal patterns.

RESULTS

Improvement of surveillance for all diarrhea episodes denoted an initial morbidity increase from 1995 to 1999, followed by a decrease by 2002, without any seasonal pattern. However, from 1990 to 1995, morbidity for severe diarrhea decreased 63%. From 1996 to 2002, 62-68% of severe diarrhea episodes occurring during the fall-winter season (FWS) were rotavirus-positive compared with 6-12% in the spring-summer season (SSS). From 1990 to 2002, diarrhea mortality decreased 84%. Higher mortality rates for children younger than 1 year old coincided precisely during the FWS, annually. Both severe diarrhea episodes and diarrhea deaths denoted a changing seasonal pattern. In 1990-1991, 2 waves of increased diarrhea activity occurred. The increase in SSS was much more pronounced than that in FWS. From 1992 to 1995 for severe diarrhea and from 1993 to 2002 for diarrhea deaths, the SSS frequencies subsequently reduced, whereas the FWS peaks remained annually.

CONCLUSIONS

A significant reduction in morbidity and mortality of severe diarrhea has occurred from 1990 and 2002 in Mexican children younger than 5 years old. This is a consequence of preventive programs initiated for cholera control since 1991, which had greater impact on SSS diarrhea and limited response for FWS diarrhea, when rotavirus is mainly present. Currently rotavirus diarrhea requires new prevention strategies and specific control measures, such as a specific national vaccine program.

Global illness and deaths caused by rotavirus disease in children

To estimate the global illness and deaths caused by rotavirus disease, we reviewed studies published from 1986 to 2000 on deaths caused by diarrhea and on rotavirus infections in children. We assessed rotavirus-associated illness in three clinical settings (mild cases requiring home care alone, moderate cases requiring a clinic visit, and severe cases requiring hospitalization) and death rates in countries in different World Bank income groups. Each year, rotavirus causes approximately 111 million episodes of gastroenteritis requiring only home care, 25 million clinic visits, 2 million hospitalizations, and 352,000-592,000 deaths (median, 440,000 deaths) in children <5 years of age. By age 5, nearly every child will have an episode of rotavirus gastroenteritis, 1 in 5 will visit a clinic, 1 in 65 will be hospitalized, and approximately 1 in 293 will die. Children in the poorest countries account for 82% of rotavirus deaths. The tremendous incidence of rotavirus disease underscores the urgent need for interventions, such as vaccines, particularly to prevent childhood deaths in developing nations.

Rotavirus vaccines: development, current issues and future prospects

The potential benefit of safe and effective rotavirus vaccination in reducing morbidity and especially mortality from rotavirus gastroenteritis among children in developing countries has long been recognised. More recently, the focus of attention shifted to developed countries, where cost-effectiveness analyses justified the routine introduction of rotavirus vaccines into childhood immunisation schedules. The recent withdrawal in the U.S.A. of the first licensed rotavirus vaccine (the tetravalent rhesus reassortant rotavirus vaccine), following investigation into reports of intussusception among a number of vaccinees, has directed attention once more towards rotavirus vaccine use in developing countries. However, issues relating to vaccine safety, efficacy, and cost, remain to be overcome before widespread introduction of rotavirus vaccines can be anticipated.

[Hospitalization for acute community-acquired rotavirus gastroenteritis: a 4-year survey]

OBJECTIVE

To evaluate the number of hospitalizations due to community-acquired rotavirus acute gastroenteritis in a general pediatric unit during a four-year survey.

RESULTS

From January 1997 to December 2000, 725 patients were admitted for acute gastro-enteritis to the general paediatric unit of a Parisian children hospital (nosocomial diarrhoea excluded) and 706 (97.5%) of these patients had had a stool microbiologic examination. Diarrhoea was caused by rotavirus in 359 patients (50.89%) and Salmonella sp in 61 (8.6%). Children and infants hospitalized for rotavirus acute gastroenteritis were younger (26% had three months or less, and 50.03% had six months or less) than in other European studies.

CONCLUSION

This study is the first in France reporting a systematic survey of hospitalized gastroenteritis during four years. More than half of hospitalized community-acquired gastroenteritis were due to rotavirus in this Parisian area. The young age of patients should be investigated in other French areas, searching for risk factors and rotavirus strains.

Rotavirus in Ireland: national estimates of disease burden, 1997 to 1998

BACKGROUND

We estimated the disease burden caused by rotavirus hospitalizations in the Republic of Ireland by using national data on the number of hospitalizations for diarrhea in children and laboratory surveillance of confirmed rotavirus detections.

METHODS

We examined trends in diarrheal hospitalizations among children <5 years old as coded by ICD-9-CM for the period January, 1997, to December, 1998. We collated data on laboratory-confirmed rotavirus detections nationally for the same period among children <2 years old. We calculated the overall contribution of rotavirus to laboratory-confirmed intestinal disease in children <5 years old from INFOSCAN, a disease bulletin for one-third of the population. We compared data from all sources and estimated the proportion of diarrheal hospitalizations that are likely the result of rotavirus in children <5 years old.

RESULTS

In children <5 years old, 9% of all hospitalizations are for diarrheal illness. In this age group 1 in 8 are hospitalized for a diarrheal illness, and 1 in 17 are hospitalized for rotavirus by 5 years of age. In hospitalized children <2 years old, 1 in 38 have a laboratory confirmed rotavirus infection.

CONCLUSIONS

The disease burden of rotavirus hospitalizations is higher than in other industrialized countries. Access to comprehensive national databases may have contributed to the high hospitalization rates, as well as a greater tendency to hospitalize children with diarrhea in Ireland.

Hospital admissions for rotavirus infection in the Netherlands

The development of a vaccine against rotavirus (RV) infection has necessitated the estimation of the number of hospitalizations for RV infection in the Netherlands. During 1998, pediatricians have reported all hospitalizations with RV infection and supplied information on the duration of admission, clinical picture, indication for admission, and treatment. Also, data from the National Disease Registry on hospitalizations for gastroenteritis (International Classification of Disease codes 006.6. 006.8, 009, and 558.9) and laboratory surveillance data for 1996-1998 were combined in a linear regression model to indirectly estimate the incidence and proportion of hospitalizations attributable to RV infection. The direct estimate of admissions for RV infection in children aged <5 years was 0.9 per 1000, and the indirect estimate was 2.7 per 1000 in 1998 (1996, 3.4; 1997, 1.6). The proportion of hospitalizations for gastroenteritis attributable to RV ranged from 32% in 1997 to 58% in 1996.

Policy analysis of the use of hepatitis B, Haemophilus influenzae type b-, Streptococcus pneumoniae-conjugate and rotavirus vaccines in national immunization schedules

After the development of national vaccine programmes to deliver six vaccines to infants, new vaccine adoption has been limited. Analysis of the health and economic implications of new vaccination options can help national policy-makers. Country specific quantitative policy analyses were conducted to estimate the impact of vaccination against hepatitis B (HB), Haemophilus influenzae type b (Hib), Streptococcus pneumoniae (SP) and rotavirus. Disease burden, programme costs and the potential reduction of disease from vaccination was assessed for each vaccine. Without vaccination, these four vaccine preventable diseases contribute up to 4.1 million deaths in each successive birth cohort. Routine scheduled use of HB and Hib vaccines could prevent up to 1.7 million deaths; SP and rotavirus vaccines, an additional 1.4 million deaths, annually. The global cost per life-year saved ranged from $29 to $150 with great variation by income and economic groups. With a few exceptions for a few countries, these vaccines would cost a fraction of average per-capita gross domestic product to save a life-year. The addition of HB and Hib vaccines, should be considered for integration in all national immunization programmes. SP and rotavirus vaccines, with the given assumptions, would also be cost-effective. Proactive analysis of the economic and epidemiologic impact of these vaccines can hasten their introduction into national vaccination schedules.

[Coincidental outbreaks of rotavirus and respiratory syncytial virus in Paris: a survey from 1993 to 1998]

PATIENTS AND METHODS

In a pediatric hospital of Paris, from 1993 to 1998, respiratory secretions were positive for respiratory syncytial virus (RSV) in 26.3% of 4,738 children (0-5 years) examined or hospitalized for lower respiratory tract infections. Rotavirus detection was positive in stools of 23.7% of the 8,537 children of the same age with acute diarrhea.

RESULTS

The RSV epidemic peak occurred annually in Paris in December and the rotavirus outbreak peaks were observed in December/January. The winter seasonal peaks remained constant for both pathogens and the temporal appearance of these peaks was constant from 1993 to 1998. Fifty to sixty-one percent of rotavirus and 77 to 92% of RSV infections were observed in November, December or January. These simultaneous outbreaks provoked important problems in hospital organization and prevention of nosocomial infections.

CONCLUSION

The coincidence of RSV and rotavirus peaks is not found in all countries. The epidemic patterns have to be checked in other parts of France and Europe because this could be important when active immunization programs will be available for these two pathogens.

Trends in hospitalization and mortality from rotavirus disease in New Zealand infants

BACKGROUND

Rotavirus illness is associated with significant morbidity and mortality worldwide. We have examined trends in diarrheal disease in New Zealand children to determine the disease burden attributable to rotavirus and to estimate the proportion of hospitalizations preventable by vaccination.

METHODS

Hospital admissions data and laboratory records for 1994 to 1996, were obtained for children 0 to 4 years at four sites (serving -60% of the New Zealand population). Rotavirus disease burden was estimated using combined admissions and laboratory data. Severity of disease was estimated in a sample of 150 hospitalizations for rotavirus diarrhea, and the proportion of vaccine-preventable admissions was extrapolated. Mortality attributed to diarrheal causes was determined from national records for 1974 to 1993.

RESULTS

Between 1994 and 1996, 4436 children <5 years of age were hospitalized with diarrhea (1047/100000 children per year). Admissions associated with rotavirus were estimated at 1522 to 1535 (315 to 362/100000 annually). Infants between 6 and 17 months were most commonly affected (42% of all cases). More male children than female children were hospitalized (P < 0.001) and mean length of stay was calculated as 1.51 days (SD 2.35). Disease severity scoring revealed that 61.3 and 38.0% of admissions reviewed were severe and very severe, respectively. Deaths from diarrheal causes numbered 138 among children 0 to 4 years old for the 20-year period 1974 to 1993, with 18 deaths occurring between 1984 and 1993 (10 years).

CONCLUSION

Current vaccines control severe disease, suggesting that 72% of cases reviewed would be eligible for prevention. A full cost effectiveness analysis is required to demonstrate anticipated benefits of vaccination.

Rotavirus infection and rates of hospitalisation for acute gastroenteritis in young children in Australia, 1993-1996

OBJECTIVE

To determine rates of hospitalisation of young children for acute gastroenteritis in Australia, and to estimate the proportion of these admissions caused by rotavirus infection.

DESIGN

Analysis of hospital admission records, and parallel, prospectively collected data on rotavirus-positive admissions.

SETTING

Hospitals admitting young children in all Australian States and Territories in 1993-1996.

PATIENTS

All children under five years admitted to hospital for acute gastroenteritis (International Classification of Diseases, ninth revision principal diagnosis codes 003.0, 004.0-009.3 and 558.9).

MAIN OUTCOME MEASURES

Rate of hospital admission per 1000 children per year by State, and the proportion of admissions caused by rotavirus infection.

RESULTS

There were almost 20,000 hospital admissions annually in Australia for acute gastroenteritis in children under five years, at an average rate of 15/1000. An estimated 50% of these were attributable to rotavirus infection, implying a rate of hospitalisation for rotavirus-related gastroenteritis of 7.5/1000/year. Among children under two years this rate was 11.6/1000. Rotavirus incidence rates generally followed a typical seasonal pattern in temperate regions of the country, with sharp peaks in mid to late winter. Rates of hospitalisation varied markedly, even between States with apparently similar patterns of disease, while the incidence in the Northern Territory was 3-5 times higher than other States.

CONCLUSIONS

Rotavirus-related gastroenteritis is a major cause of hospital admissions in young children, and large savings to the healthcare system are possible if it can be prevented at reasonable cost. Variation in treatment practices between States may be worth studying in greater detail as another source of potential savings.

First rotavirus vaccine licensed: is there really a need?

The first rotavirus vaccine was licensed in the United States on 31 August 1998 for the prevention of severe rotavirus diarrhea in children. Despite this landmark in new vaccines, many pediatricians and public health professionals in Europe are uncertain of the need for this vaccine for the routine immunization of infants. In Europe, ample evidence suggests that rotavirus is the most common cause of hospitalizations for severe diarrhea among children, but proper studies documenting the disease burden of rotavirus or the cost-effectiveness of a rotavirus immunization program have only been conducted in the United Kingdom following epidemiologic models used in the United States. All children are infected with rotavirus during their first few years of life, 30-50% of diarrheal hospitalizations among children <5 years are due to this agent, and, by the age of 5 years, between 1 in 40 and 1 in 77 children in Europe and the United States may be hospitalized for rotavirus. The first vaccine is a live, oral preparation combining four different serotypes of rotavirus and administered in three doses with other childhood immunizations. The good efficacy against severe rotavirus diarrhea, the low risk of adverse side effects and the positive cost-effectiveness equation have led the two major immunization advisory groups in the U.S. to recommend this vaccine for routine use in American infants. European physicians and policy-makers should re-examine the epidemiology and disease burden of rotavirus diarrhea now that an effective method of prevention is at hand.

An estimate of the proportion of diarrhoeal disease episodes seen by general practitioners attributable to rotavirus in children under 5 y of age in England and Wales

Mean weekly incidence rates for a 4-week period of new episodes of infectious intestinal disease (IID) and laboratory reports of faecal isolations in children under 5 y of age presenting in general practice were used to estimate the incidence of IID due to rotavirus infection in England and Wales. Between January 1992 and December 1996, a total of 92452 new episodes of IID were seen at sentinel general practices and reported to the Royal College of General Practitioners (RCGP) Research Unit in Birmingham, UK. Of these 32% (29592) were in children under 5 y of age. During the same period the Communicable Disease Surveillance Centre (CDSC) in London, UK received 159532 reports of faecal identifications in children under 5 y of age; 69219 (43%) of these were due to rotavirus. By modelling RCGP data and laboratory reports, the proportion of episodes attributable to rotavirus infection was estimated to be 29% (95% CI: 24% to 34%). By extrapolation of RCGP data it was estimated that rotavirus accounted for 762000 of new episodes of IID nationally in children under 5 y of age between January 1992 and December 1996. Implementation of a rotavirus vaccination programme could substantially reduce the incidence of childhood diarrhoea.

Rotavirus gastroenteritis: impact on young children, their families and the health care system

OBJECTIVE

To assess the impact of rotavirus gastroenteritis on young children attending a paediatric hospital, their families and the health care system.

DESIGN

Cross-sectional descriptive survey.

SETTING

New Children's Hospital (Royal Alexandra Hospital for Children), Sydney, New South Wales, 15 July to 4 October 1996.

PARTICIPANTS

Children aged under three years attending the Emergency Department with acute diarrhoea as the presenting symptom.

OUTCOME MEASURES

Cases of rotavirus infection confirmed by enzyme-linked immunosorbent assay by age; rotavirus serotype; gastroenteritis severity score; estimated costs to parents (lost pay or leave, travel, medication and other expenses) and to the health care system (visits to Emergency Department and other health care workers, hospital admissions).

RESULTS

280 children were recruited (73% of 384 children who met the inclusion criteria and 27% of the 1037 aged under three years with acute gastroenteritis). Rotavirus was detected in 188 of the 280 (67%); most isolates were serotype G1 (86% of the 174 serotyped). Of the 188 children with confirmed rotavirus infection 78% were aged 7-24 months and 82% visited at least one other health care worker, usually a general practitioner. Seventy (37% of the 188) were admitted to hospital; 33 of these (47%) were aged 13-24 months. Estimated mean total cost per episode of rotavirus gastroenteritis was $1744 for children admitted to hospital and $441 for children not admitted. The mean cost to families was $493 for children admitted to hospital and $228 for children not admitted.

CONCLUSIONS

Rotavirus gastroenteritis has a significant impact on young children, their families and the health care system. Prevention of severe disease through routine infant vaccination would be potentially cost-effective.

Longitudinal study of rotavirus infection in child-care centres

OBJECTIVE

To describe the epidemiology of symptomatic and asymptomatic rotavirus infection among young children attending Sydney child-care centres during the 1994 rotavirus season.

METHODS

Children aged 0-36 months in 11 child-care centres participated in the study. A weekly stool specimen was collected from each subject and tested for rotavirus antigen by commercial enzyme immunoassay.

RESULTS

One hundred and seventy-eight children (76 girls and 102 boys) with a mean age of 18.2 +/- 6.5 (SD) months were enrolled for a total of 2249 child-weeks. Of 1653 weekly faecal specimens, 59 (3.6%) were positive for rotavirus antigen. Positivity for rotavirus antigen peaked at 8.0% and 7.4% of specimens in weeks 6 and 7, respectively. The 59 positive specimens were obtained from 44 children in eight of the 11 study centres. One child appeared to suffer a second episode. Eighty-two per cent of episodes were associated with symptoms of gastroenteritis. Overall, 32% of the children in the eight affected centres were infected; 52% of those < 12 months were infected compared to 26% of older children. Secondary spread to household contacts was also documented.

CONCLUSIONS

Rotavirus infection poses a significant health problem in under-3-year-old children attending child-care centres in Sydney. We believe that these results are applicable to all Australian children of this age attending group child care.