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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. 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