Download (66 /104, 63%) with no difference in that proportion among RPG and

Incidence of Rotavirus in children hospitalized for Gastroenteritis in Saqr Hospital, Ras
Al Khaima, United Arab Emirates- Pilot Study
Dr. Mahmood Y. Hachim1, Dr. Tarek El Etreby1, Dr. Khawla Abdulla Drweesh2, Dr. Yaser Al
Nuaimi 2 and 3
(1)Department of Medical Microbiology and Immunology, RAK Medical and Health Sciences University,
(2)Pediatric Consultant, Pediatric Department, Saqr Hospital, (3)Director, RAK Medical District,
Pediatrician,RAK-UAE
Corresponding author:
Dr. Mahmood Y. Hachim
Lecturer, Department of Medical Microbiology and Immunology, RAK Medical and Health Sciences
University, RAK-UAE
Email : [email protected]
Abstract:
Rotavirus infection, a leading cause of severe diarrhea among children aged <5 years kills
600,000 children every year.
Objective: To estimate the burden and epidemiology of rotavirus gastroenteritis in children less
than 5 years of age.
Methods: A prospective study on pediatric patients admitted with acute gastroenteritisincluded
all patients aged 0–12 years hospitalized between 15 January 2012 and 15 May 2012 with a
diagnosis of acute gastroenteritis, rotavirus gastroenteritis, acute diarrhea, or diarrhea and
vomiting. Patients were excluded if they had diarrhea lasting more than 7 days, inflammatory
bowel disease or other chronic disease causing diarrhea, were hospitalized for intoxication, or
had malformations of the gastrointestinal tract.
Results: 104 patients were included and 48(46%) cases were tested positive for rotavirus
while 56 (54%)were negative. 66 out of 104 (63%) were under 2 years age. Other demographic
variables showed no significant difference between RPG and RNG. The majority of children
attending hospital with rotavirus gastroenteritis had some degree of metabolic acidosis and
electrolytes imbalance.During the year, weeks with lower temperature and higher humidity have
higher number of cases compared to other weeks.
Conclusion: A high incidence of Rotavirus gastroenteritis necessitates the implementation of
national vaccination program. The majority of rotavirus disease occurredin children under 6
months of age. This age comes after the completionof routine rotavirus vaccination that means
most rotavirus GE hospitalizations can be preventableby the standard rotavirus vaccination
schedule
Introduction:
Diarrheal diseases constitute a critical, global, public-health problem, for being a major cause of
illness and death among infants and young children in developing countries [14].Globally,
Rotavirus is the single most common organism causing acute gastroenteritis in children, when
all children will experience at least one episode of rotavirus infection by the time they are 5
years of age that will need hospitalization [15, 20]. More than 80% of all rotavirus-related
deaths occurring in resource-poor countries in south Asia and sub-Saharan Africa[13]. Unlike
many bacteriological agents of diarrhoeal illness, rotavirus occurs in both temperate and tropical
areasas universal diseases of children, regardless of the level of hygiene that prevails or the
quality of food and water [9].Rotavirus gastroenteritis imposes a heavy economic burden, by
incurring direct (consultation, emergency, hospitalization, medication) and indirect costs (parent
work days lost, baby-sitting, additional diapers) [6].
The incidence of hospitalization for acute gastroenteritis (AGE) is a useful parameter to assess
the utility of the new rotavirus vaccines in high-income countries like United Arab Emirates
(UAE). AGE produces important dysfunctional experiences in daily family life. According to
parental perceptions, Rota infections produces greater worries and dysfunctions in child
behavior[2]. Parents of a child with acute Rota virus acute gastroenteritis (RVGE) presenting to
primary care experience worry, distress and disruptions to daily life as a result of the child's
illness. Prevention of this disease through prophylactic vaccination will improve the daily lives
of parents and children [8].
Because testing for rotavirus is not routinely performed in children with acute gastroenteritis,
these estimates of rotavirus disease burden have been derived primarily by using indirect
approaches [7].5% of all-cause under-5 child mortality and up to 36% of under-5 gastroenteritis
hospitalizations across the globe could be prevented by using rotavirus vaccines [11].
In 2009, WHO recommended that rotavirus vaccine be included in all national immunization
programmes [18]. The recognition of the worldwide disease burden and the potential for
prevention of morbidity and mortality through vaccines led to the establishment of a number of
national and regional rotavirus surveillance networks [18]. Nosocomial rotavirus (nRV)
infections represent an important part of rotavirus (RV)-associated morbidity. [12]
Implementingthe new rotavirus vaccines, which have ademonstrated efficacy of 80%–98%
against severerotavirus disease in high-income settings andhave already shown tremendous
public health impact inmany countries that have implemented routine childhoodvaccination,
could prove to be a potentially usefulstrategy to improve and protect the health of children in
developed countries.[3]
As the burden of illness data specific to the Middle East and North Africa is limited [4].In UAE,
Rotavirus was detected in 21.4% of the samples examined, the predominant number of positive
cases (35%) were in the 7–12 months age group. It was interesting to find rotavirus-positive
cases in as low an age group as <3 months (3.6%) and as high as 10 years (8.04%) [5].
Aim of the Study
The purpose of this study was to estimate the disease burden and epidemiology of rotavirus
gastroenteritis in children less than 5 years of age, in Ras Al Khaima-United Arab Emirates.
Acute gastroenteritis cases will be identified by Pediatrician from acute gastroenteritis
hospitalisation decision and stool samples will be collected from all suspected and confirmed
acute gastroenteritis cases.
Materials and Methods
We conducted a prospective study on pediatric patients admitted with acute gastroenteritis to
the pediatric ward in Saqr Hospital, Ras Al Khaima. The study group included all patients aged
0–18 years hospitalized between 15 January 2012 and 15 May 2012 with a diagnosis of acute
gastroenteritis, rotavirus gastroenteritis, acute diarrhea, or diarrhea and vomiting. Patients were
excluded if they had diarrhea lasting more than 7 days, inflammatory bowel disease or other
chronic disease causing diarrhea, were hospitalized for intoxication, or had malformations of
the gastrointestinal tract.
Patient Criteria for inclusion: Children under the age of 5 years, presenting with acute onset of
fever and vomiting followed 24 to 48 hours later by watery diarrhea, More than 3 bowl
movement per day with loose stool. Dehydration will be defined according to definitions of the
World Health Organization. When parents reported a history of fever, the fevers were classified
as present or absent.
After informed consent, a clinical history and physical examination was recorded on a
structured, pretested questionnaire. Since subjects are infants and young children, parents or
guardians were asked to provide the information. All subjects completed questionnaires, which
gathered demographic information such as age, gender, and nationality, area of residencewater
source, recent diet and health history.
The clinical variables were dehydration, diarrhea characteristics, vomiting, vital signs, weight,
temperature, nutrition, and treatment in the house (antibiotics and rehydration fluids). Blood
samples were collected and examined for serum sodium, potassium, chloride, bicarbonate,
blood urea nitrogen (BUN), creatinine and complete blood counts (CBC). Acidosis was
determined by serum electrolytes only. Stool examination for rotavirus was tested with
immunochromatography assay (VIKIA® Rota-Adeno, BioMérieux, France).
Daily temperature and humidity
http://www.wunderground.com/ .
was
obtained
from
online
weather
service
Statistical analysis
Patients with rotavirus gastroenteritis were compared to patientswith other causes of
gastroenteritis using the chi-square test forcategorical variables and Students t-test for
continuous variables. P < 0.05 was consideredsignificant. Patients with a missing value for any
variablewere omitted from analysis of the specific variable. Microsoft Excel 2010 was used and
StatFlex V6.
Results
Of the 131pediatric patients admitted to the pediatric department during the period from January
2012 till May 2012, 104 (80%) were under five years oldand were included for the study.
Basedon the exclusion criteria, 27 cases were excluded due to thespecified criteria, missing
data, or patients who were nottested for rotavirus in the stools. Out of104 patients: 48(46%)
cases were tested positive for rotavirus, and 56 (54%)were negative. The demographicfeatures,
clinical characteristics and laboratory findings of thestudy population are listed in Table 1.
Demographic variables
66 out of 104 (63%) were under 2 years age. Average age was 2.04± (1.26) years. Patients with
RPG hadmean age of 1.94± (1.12) while those with RNG had mean age of 2.12± (1.38), there
was no statistical difference between the two groups. 61out of 104 (59%) were males and 30 out
of 48 RPG were males (63%). There was no significant difference between the males and
females in concern with Rotavirus incidence.
Table (1): Demographic variables (age, sex, month of admission) of the study group
Demographic Variables
Age (mean ±(SD)
Under 2 years (n, (%))
Older 2 years (n, (%))
Male (n, (%))
Female (n, (%))
RPG (n=48)
RNG (n=56)
RPG (n=48)
1.94±(1.12)
30(63%)
18(38%)
30(63%)
18(38%)
2.12±(1.38)
36(64%)
20(36%)
31(55%)
25(45%)
2.04±(1.26)
66(63%)
38(37%
61(59%)
43(41%)
P
0.913
0.850
Not significant
Significance
0.590
Not significant
Not significant
The incidence of gastroenteritis was higher during February 47/104 (45%) without significant
difference between RPG and RNG. When weekly average temperature was plotted against
number of RPG per week, it was found that weeks with lower temperature and higher humidity
will have higher number of cases compared to other weeks (P=0.025,P=0.033, respectively).
Table (2): Monthly number of cases of Gastroenteritis
Demographic Variables
Month of
admission
15-31 January
1-28 February
1-30 March
1-31 April
1-15 May
RPG (n=48)
RNG (n=56)
All GE (n=104)
P
Significance
5 (10%)
24 (50%)
6 (13%)
6 (13%)
7 (15%)
7 (13%)
23 (41%)
10 (18%)
8 (14%)
8 (14%)
12 (12%)
47 (45%)
16 (15%)
14 (13%)
15 (14%)
0.859
Not significant
Table (3): Average temperature and humidity versus weekly cases number
Number of Weekly cases
of RPG
No Cases
1 to 4
5 to 8
P Value
Temperature
Mean
29.323
24.017
20.457
Humidity
SD
6.983
4.128
0.981
Mean
42
52
59
SD
13.374
7.705
5.530
0.025
0.033
Other demographic variables showed no significant difference between RPG and RNG
regarding patient Nationality, Mother Education Level, Residency Type (apartment or villa),
Family Type (single or extended family),Feeding Habit (breast feeding, artificial milk , home
prepared food), water supply and monthly family income.
Table (4): Socio-economic variables (nationality, mother education level, resident type,
family type, feeding habit) of the study group
RPG (n=48)
Nationality
Arabs
Asian
African
European
Americans
Mother Education Level
Illiterate
Can read and write
Primary Education
Secondary Education
College
Residency Type
Villa
Apartment
Family Type
Single family
Complex family
Feeding Habit
Breast Feeding (BF)
Artificial Milk (AM)
Home Food (HF)
BF+AM
BF+HF
AM+HF
Water Source
Dispenser
Family Monthly Income
Pipelines
2000-5000AED
>5000
<2000AED
43
3
1
0
0
2
16
2
8
17
31
4
24
13
3
6
18
4
5
8
48
0
7
34
0
90%
6%
2%
0%
0%
4%
33%
4%
17%
35%
65%
8%
50%
27%
6%
13%
38%
8%
10%
17%
100%
0%
15%
71%
0%
RNG (n=56)
44
12
0
0
0
7
15
3
12
12
29
6
33
8
3
8
23
3
8
7
52
4
12
35
2
79%
21%
0%
0%
0%
13%
27%
5%
21%
21%
52%
11%
59%
14%
5%
14%
41%
5%
14%
13%
93%
7%
21%
63%
4%
All GE (n=104)
87
15
1
0
0
9
31
5
20
29
60
10
57
21
6
14
41
7
13
15
100
4
19
69
2
84%
14%
1%
0%
0%
9%
30%
5%
19%
28%
58%
10%
55%
20%
6%
13%
39%
7%
13%
14%
96%
4%
18%
66%
2%
P
0.109
Not significant
Significance
0.295
Not significant
0.235
Not significant
0.117
Not significant
0.955
Not significant
0.056
Not significant
0.267
Not significant
Chief complaints and associated symptoms
Diarrhea was the chief complaint in 89 out of 104 (86%) patients followed by vomiting,
abdominal pain and fever (11%, 3% and 1%) respectively.
Table (5): Chief complaints in the study group
Chief Complaints
Diarrhea
Vomiting
Abdominal pain
Fever
RPG (n=48)
N
43
4
1
0
%
90%
8%
2%
0%
RNG (n=56)
N
46
7
2
1
%
82%
13%
4%
2%
All GE (n=104)
N
89
11
3
1
%
86%
11%
3%
1%
P
Significance
0.760
Not significant
Taking history of the present illness revealed that 93 out of 104 patients (89%) had vomiting,
92(88%) had diarrhea, 67(64%) had fever, 35(34%) had abdominal pain, 24(23%) with blood in
stool and 23(22%) loss their appetite. There were no significant difference between the
incidence of these symptoms among RPG and RNG.
Table (6): Associated Symptoms in the study group
Associated Symptoms
Vomiting
Diarrhea
Fever
Abdominal pain
Blood in stool
Loss of appetite
Mucous in stool
Runny nose
Cough
RPG (n=48)
N
44
42
29
16
13
13
6
5
3
%
96%
91%
63%
35%
28%
28%
13%
11%
7%
RNG (n=56)
N
49
50
38
19
11
10
11
3
5
%
88%
89%
68%
34%
20%
18%
20%
5%
9%
All GE (n=104)
N
93
92
67
35
24
23
17
8
8
%
89%
88%
64%
34%
23%
22%
16%
8%
8%
P
Significance
0.541
Not significant
0.579
Not significant
0.559
Not significant
0.949
Not significant
0.507
Not significant
0.372
Not significant
0.428
Not significant
0.466
Not significant
0.723
Not significant
Clinical Signs and Initial Assessment
On admission, 39 of 104 (37.5%) had fever >38 oC, 19(18%) had tachycardia, 41(39%) had
tachypnea with average weight of 11.42± (3.98) kilograms. 86 of 104 (82%) had dehydration ,
most of them , 60 of 104 (57%) had mild degree of dehydration. Although there was no
significant difference between RPG and RNG in heart rate, respiratory rate , weight,
dehydration, the incidence of tachycardia was higher in RNG compared to RPG, 13 of 56 (23%)
Vs. 6 of 48 (13%), the incidence of tachypnea was higher in RPG compared to RNG, 21 of 56
(38%) Vs. 20 of 48 (42%). Incidence of dehydration was higher in RPG (42 of 48, 85.7%) Vs.
44 of 56 (74.5%) in RNG.
Table (7): Clinical Signs and Initial Assessment in the study group
Co (SD)
Temperature Mean
Fever >38 Co(n (%))
Pulse Rate (rate ± SD)
Tachycardia>140(n (%))
Respiratory Rate (rate ± SD)
Tachypnea >30 (n (%))
Weight (Kgs ± SD)
Dehydration

Severe

Moderate

Mild
RPG (n=48)
RNG (n=56)
All GE (n=104)
37.728±0.869
19 (39%)
130.11± (14.57)
6.00(13%)
32.14±(4.56)
20(42%)
11.10± (3.86)
42(85.71%)
37.684±1.229
20 (35%)
133.88± (17.46)
13.00(23%)
34.00±(9.38)
21(38%)
11.72± (4.11)
44(74.58%)
37.705±1.068
39 (37.5%)
132.11± (16.19)
19.00(18%)
33.12±(7.52)
41(39%)
11.42± (3.98)
86(82%)
3(4.48%)
13(19.40%)
26(38.81%)
1(1.41%)
9(12.68%)
34 (47.89%)
4 (4%)
22 (21%)
60 (57%)
P
Significance
0.840
0.684
0.251
0.205
0.235
0.816
0.441
0.342
0.300
Not significant
Not significant
Not significant
Not significant
Not significant
Not significant
Not significant
Not significant
Not significant
Laboratory variables
There were only minor non-significant differences in thelaboratory findings between the two
groups. The only statistical difference was noticed in the level of serum bicarbonate, RPG had
lower level than RNG 17.91± (2.94), 20.98± (4.39), P = 0.001, respectively. Another significant
difference was in the presence of white blood cells in stool was higher in RPG than RNG, 40 of
48 (87%) Vs. 35 of 56 (63%), P=0.028. 26 of 104 (25%) patients with GE showed positive stool
culture for bacteria, this percentage was the same among RPG and RNG, indicating that 25% of
children with GE can present with mixed pathogens.
Table (8): Laboratory findings in the study group
Laboratory Results
Sodium (mmol/L); mean (SD)
Potassium (mmol/L); mean (SD
Bicarbonate (mmol/L); n (%)
Chloride (mmol/L); mean (SD)
Creatinine (μmol/L)
Hyponatremia (sodium <135 mmol/L); n (%)
Hypokalemia (potassium <3.5 mmol/L); n (%)
Acidosis (bicarbonate <15 mmol/L); n (%)
Haemoglobin (g/L); mean (SD)
White blood cell count* (x109/L
Presence WBC in stool; n (%)
Presence of RBC in stool; n (%)
Stool Culture Positive for bacteria, n (%)
Stool Positive Ova/Parasites, n (%)
RPG (n=48)
140.64±(4.41)
3.83±(0.59)
17.91± (2.94)
102.30±(14.87)
40.60±(12.02)
4.00(9%)
9.00(20%)
4.00(9%)
11.89±(1.01)
12.01±(3.43)
40(87%)
34(74%)
12(24%)
1(2%)
RNG (n=56)
141.04±(3.21)
3.89±(0.47)
20.98± (4.39)
104.35±(3.71)
42.92±(12.73)
1.00(2%)
7.00(13%)
2.00(4%)
11.51±(1.20)
12.12±(4.60)
35(63%)
32(57%)
14(25%)
1(2%)
All GE (n=104)
140.85±(3.80)
3.86±(0.53)
19.36± (3.98)
103.36±(10.67)
41.76±(12.38)
5.00(5%)
16.00(15%)
6.00(6%)
11.69(1.12)
12.07±(4.08)
75(64%)
66(56%)
26(25%)
2(2%)
P
0.614
0.546
0.001
0.357
0.379
0.172
0.423
0.411
0.107
0.895
0.028
0.215
0.951
0.923
Significance
Not significant
Not significant
Highly significant
Not significant
Not significant
Not significant
Not significant
Not significant
Not significant
Not significant
Highly significant
Not significant
Not significant
Not significant
Home Management
Most of the parents of children, 65 of 104 (63%) did nothing except seeking medical advice
while 29 (28%) they started oral rehydration at home, 6(6%) start antibiotics while 3(3%) tried
antimotility drugs. There was no statistical difference among RPG and RNG (P=0.697).
Table (9): Laboratory findings in the study group
Home Management
Anti-motilityn (%)
Antibioticsn (%)
Rehydrationn (%)
Nothing specific n (%)
RPG (n=48)
1(2%)
2 (4%)
15(31%)
30 (63%)
RNG (n=56)
2(4%)
5 (9%)
14(25%)
35(63%)
RPG (n=48)
3 (3%)
6 (6%)
29 (28%)
65 (63%)
P
0.697
Significance
Not significant
Discussion and Conclusions
In this pilotprospective study on cohort of children admitted to Saqr hospital with
gastroenteritis, we found that rotavirus was responsible for 46% of admissions for
acutegastroenteritis episodes. It is higher than Taleb et al finding of annual proportion in the
Middle East and North Africa region which is 42% [17], and higher than a nearby Gulf country
(Saudi Arabia) where the prevalence ranged between 10% to 46% with a median of 30% [10].
This difference may beattributed to the fact that our study included only hospitalizedchildren for
gastroenteritis that was assessed by pediatrician to decide whether they need hospitalization or
not. It may reflect actual differences in RVGE proportion but may also be related to variations
in study design.
Regarding patients age and sex, most of the cases of gastroenteritis were under 2 years old (66
/104, 63%) with no difference in that proportion among RPG and RNG. Children with rotavirus
gastroenteritis were in same age of patients with gastroenteritis and negative stool rotavirus
antigen test; this is not the case in Zafer et al, who found that Children with rotavirus
gastroenteritis wereyounger[21]. There was no difference in the incidence of RPG among
males and females and this is the same finding that Rotaviruspositivepatients were nearly
identical torotavirus-negative patients with respect to sex. [21]
As previously indicated by Kamyia et al , the majority of rotavirus disease occurredin children
under 6 months of age. This is the age is after the completionof routine rotavirus vaccination
that means most rotavirus GE hospitalizations should be preventableby the standard rotavirus
vaccination schedule [3].
Our study is limited from mid-January till mid-May and most of cases of gastroenteritis in
summer are not included, this can explain the higher proportion in our study, despite this
limitation, rota virus was the mostcommonly detected etiologic agent in acute gastroenteritis
that need hospitalization. Rotavirus seasonstarted gradually in October, peaked in Januaryto
March, and lasted until May. It was documented previously that, in winter months,rotavirus was
detected in approximately 60-65%of the cases with acute gastroenteritis, while in thesummer
the proportion of rotavirus gastroenteritiswas lower than 20%.[21]
Since not all children of Ras Al Khaima with gastroenteritis weretested for rotavirus, the true
incidence rate of RPG might have been lower, some patients with subclinical forms were not
tested because they hada milder disease.
The incidence of gastroenteritis was higher during February 47/104 (45%) without significant
difference between RPG and RNG. When weekly average temperature was plotted against
number of RPG per week, it was found that weeks with lower temperature and higher humidity
will have higher number of cases compared to other weeks (P=0.025,P=0.033, respectively).
There was no significant difference amongrotavirus-positive and –negative patients withregard
to nationality, mother education level, residency type, family type, and family monthly income.
implying that epidemiological datahave limited value in suggesting the diagnosis of RPG
There was no significant difference amongrotavirus-positive and –negative patients withregard
to water source whether piped or through dispenser bottles, this goes with previous findings that
the detection rates ofrotavirus in children who had a source of pipedwater in their homes were
similar to those wholacked a source of piped water[21].
Our results showed no significant difference between RPG and RNG regarding their feeding
habit, this contradicts a previous note of Zafer et al , wo stated that there was asignificant
association between rotavirusdiarrhea and being not exclusively breast-fed in the first six
months of life[21].As a summary, providing clean watersupplies and good hygiene have not
decreased theincidence of rotavirus gastroenteritis.
Rotavirus infection was similar in presentation as chief complaints or associated symptoms, and
routine laboratory findings, the home management choices by parents from gastroenteritis
caused by other causes. This is in contrast with previous study in Thailand which stated
thatrotavirus diarrhoeachildren had significant higher rate ofvomiting as presenting symptom ,
lower prevalence rate of feverand higher rate of significantdehydration were observed
inrotavirus group compared to non-rotavirus diarrhea group.[16]
No difference in severity of gastroenteritis between RPG and RNG. Previous reports showed
that theassociation between rotavirus and severediarrhea is conflicting, some studies indicated
that childreninfected with rotavirus had less severedehydration than those infected with other
enteropathogens. But some reports said that Rotavirus was also foundnot to be associated with
severe dehydration, in both cases they relied onhospitalizations as an indicator of severe
rotavirus gastroenteritis but admission to ahospital can be influenced by socio-economicfactors
and/or by the doctor’s attitude. Interestingly, in our study we documented that dehydration ,
which was the main complication of GE, showed no significant differences between the
twogroups and this goes with Thuppal et al findings.[18]
There was no statistical significant difference between RPG and RNG in the results of
stoolcultures and routine tests, the laboratory findingsin both groups were similar and hence of
no value as a tool todifferentiate rotavirus and non-rotavirus infectious gastroenteritis.
The only significant difference was the lower level of serum bicarbonate in RPG compared to
RNG (p=001) indicating metabolic acidosis. This goes with previous finding that the majority
of children attending hospital with rotavirus gastroenteritis had a metabolic acidosis. [1]
Bicarbonate ions werelost more in rotavirus group of children, which ultimately developed
acidosis. Infectionto gut cells lead to lesser fluid absorptioncould be a possible explanation for
developedacidosis. Moderate dehydration led to highernitrogen in blood in form of urea [16].
Another significant finding that the presence of WBC in stool was higher (87%) (p=0.02), this
is far away from previous study by Chung Wu et al, who stated that leukocytes in stools were
found in 3% and 4% ofpatients with rotavirus and norovirus gastroenteritis,respectively, with no
significant difference [19].
Acknowledgments
Dr. Nahed I. Gomaa, Nurses of Pediatrics, Laboratory and Outpatient departments, Saqr
Hospital, RAKMHSU Vice Chancellor and RAKCOMS Dean.
References
1. Anshoo Dhelaria , Raghuram Commondoor , Ananya Kar , and Michael Eisenhut , Characteristics of
metabolic acidosis and management of rotavirus gastro-enteritis. J Pediatr Biochem 2010; 1 (4): 297301.
2. Giménez Sánchez F, Delgado Rubio A, Martinón Torres F, Asensi Botet F, Miranda Valdivieso M,
Gómez Llorente JL, Alfayate Miguélez S, Carmona Martínez A, Romero González J, Crespo Hernández
M, Baca Cots M, Solís Sánchez P, López Soler JA, Lozano de la Torre MJ, Ruiz Contreras J, Pineda
Solas V, Manrique Martínez I, García Pérez J, Bernaola Iturbe E, del Valle Millán JM, Moya Benavent
M, Ortigosa Castillo L, Romero Blanco I, Román Riechmann E, Vizcay Vilella JM, Sesmero Lillo MA,
Gonzalo de Liria CR, Serrano Poveda E, de Juan Martín F, Loriente Tur M; Grupo An Pediatr (Barc).
[Family impact of rotavirus gastroenteritis in children under two years]. 2008 Dec;69(6):515-20.
3. Hajime Kamiya, Takashi Nakano, Hitoshi Kamiya, Akiko Yui, Koki Taniguchi, and Umesh Parashar,
Rotavirus-Associated Acute Gastroenteritis Hospitalizations among Japanese Children Aged <5 Years:
Active Rotavirus Surveillance in Mie Prefecture, Japan, Jpn. J. Infect. Dis., 64 (6), 482-487 , 2011
4. Hanane Khoury, Isla Ogilvie, Antoine C El Khoury, Yinghui Duan and Mireille M Goetghebeur ,
Burden of rotavirus gastroenteritis in the Middle Eastern and North African pediatric population, , BMC
Infectious Diseases 2011, 11:9
5. Ijaz M.K., Alharbi S., Uduman S.A., Cheema Y., Sheek-Hussen M.M., Alkhair A.R.A., Shalabi A.G.,
Liddle L.F. Seasonality and prevalence of rotavirus in Al-Ain, United Arab Emirates, (1994) Clinical
and Diagnostic Virology, 2 (6), pp. 323-329.
6. Isla Ogilvie, Hanane Khoury, Antoine C. El Khoury and Mireille M. Goetghebeur, Burden of rotavirus
gastroenteritis in the pediatric population in Central and Eastern Europe Serotype distribution and
burden of illness , Human Vaccines 7:5, 523-533; May 2011
7. Jacqueline E. Tate, Aaron T. Curns, Margaret M. Cortese, Eric S. Weintraub, Simon Hambidge ,
Kenneth M. Zangwill, Manish M. Patel, MD, James M. Baggs, Umesh D. Parashar, Burden of Acute
Gastroenteritis Hospitalizations and Emergency Department Visits in US Children That Is, Potentially
Preventable by Rotavirus Vaccination: A Probe Study Using the Now-Withdrawn RotaShield Vaccine ,
Pediatrics Vol. 123 No. 3 March 1, 2009 , pp. 744 -749
8. Javier Diez-Domingo, Marian Patrzalek, Luigi Cantarutti, Benoit Arnould, Juliette Meunier, Montse
Soriano-Gabarro, Nadia Meyer, Jean-Yves Pirçon and Katsiaryna Holl , The impact of childhood acute
rotavirus gastroenteritis on the parents' quality of life: prospective observational study in European
primary care medical practices, MC Pediatrics 2012, 12:58
9. Karen Levy, Alan E Hubbard, and Joseph NS Eisenberg, Seasonality of rotavirus disease in the tropics:
a systematic review and meta-analysis, Int. J. Epidemiol., Dec 2009; 38: 1487 - 1496.
10. Kheyami AM, Cunliffe NA, Hart CA. , Rotavirus infection in Saudi Arabia., Ann Saudi Med. 2006
May-Jun;26(3):184-91.
11. Kristen D.C. Lewis, Michael J. Dallas, John C. Victor, Max Ciarlet, T. Christopher Mast, Ming Ji ,
George Armah, K. Zaman, Aimee Ferraro, Kathleen M. Neuzil, Comparison of two clinical severity
scoring systems in two multi-center, developing country rotavirus vaccine trials in Africa and Asia,
Vaccine 30S (2012) A159– A166.
12. Patricia Bruijning-Verhagen, Caroline Quach, and Marc Bonten , Nosocomial Rotavirus Infections: A
Meta-analysis, Pediatrics, Apr 2012; 129: e1011 - e1019
13. Penelope H. Dennehy , Rotavirus Vaccines: an Overview, Clin. Microbiol. Rev., Jan 2008; 21: 198 208.
14. Prasong Pruksananonda, Krairerk Athirakul, Mingmuang Worawattanakul, Wandee Varavithya, Ampai
Pisithpun, Dwip Kitayaporn And Sinn Anuras , Diarrhea Among Children Admitted To A Private
Tertiary-Care Hospital, Bangkok, Thailand: A Case Series, Southeast Asian J Trop Med Public Health,
Vol 39 No. 3 May 2008
15. Ran D. Goldman, Effectiveness of rotavirus vaccine in preventing severe acute gastroenteritis in
children , Can Fam Physician. 2012 March; 58(3): 270–271.
16. Sanguansak Rerksuppaphol, Lakkana Rerksuppaphol, Prevalence and clinical manifestations of
rotavirus diarrhea in children of rural area of Thailand, International Journal of Collaborative Research
on Internal Medicine & Public Health, Vol. 3 No. 9 (September 2011)
17. Teleb N: Rotavirus Surveillance Network in the Eastern Mediterranean regional
18. Thuppal V. Sowmyanarayanana, Sasirekha Ramania, Rajiv Sarkara, Rajesh Arumugama, Jubal P.
Wariera, Prabhakar D. Mosesb, Anna Simonb, Indira Agarwalb, Anuradha Bosec, Rashmi Arorad,
Gagandeep Kang, Severity of rotavirus gastroenteritis in Indian children requiring hospitalization ,
Vaccine 30S (2012) A167– A172
19. Tzee-Chung Wu, Hsioa-Hui Liu, Yann-Jang Chen, Ren-Bin Tang, Be-Tau Hwang, Han-Chih Yuan,
Comparison of Clinical Features of Childhood, Norovirus and Rotavirus Gastroenteritis in Taiwan . J
Chin Med Assoc • November 2008 • Vol 71 • No 11
20. WHO, Weekly epidemiological record, 29 APRIL 2011, 86th year / 29 , No. 18, 2011, 86, 173–176.
21. Zafer Kurugöl, Seda Geylani, Yeþer Karaca, Feyza Umay, Selda Erensoy, Fadý Vardar Mustafa Bak,
Iþýn Yaprak, Ferda Özkýnay, Cihangir Özkýnay, Rotavirus gastroenteritis among children under five
years of age in Ýzmir, Turkey, The Turkish Journal of Pediatrics 2003; 45: 290-294