Published by : PROFESSIONAL MEDICAL PUBLICATIONS
|July - September 2007||
Prevalence of group a rotavirus, enteric adenovirus, norovirus
and astrovirus infections among children with
acute gastroenteritis in Al-Qassim, Saudi Arabia
Mamdoh M. Meqdam1, Ibrahim R. Thwiny2
Objective: To investigate the prevalence of Rotavirus, Adenovirus, Norovirus, and Astrovirus among Saudi children with gastroenteritis.
Methodology: This study was conducted at the Department of Medical Laboratories, Qassim University during the winter seasons of the years 2004 and 2005. A total of 284 diarrhoeal fecal specimens collected from children were tested for the gastroenteritis causing viruses using enzyme immunoassay.
Results: Of the 284 specimens, 142 (50%) were found to be positive for viruses causing gastroenteritis. Rotavirus (66.2%) was the most frequently detected, followed by adenovirus (15.5%), norovirus and astrovirus each with 9.2%. All of rotavirus detected belonged to group A. Eight specimens were found positive by two viruses.
Conclusions: The introduction of simple and rapid tests for diagnosis of viruses causing gastroenteritis in our pediatric hospitals will improve patient care by reducing unnecessary treatments and hospital stay for patients.
KEYWORDS: Rotavirus, Enteric Adenovirus, Acute gastroenteritis.
Pak J Med Sci July - September 2007 Vol. 23 No. 4 551-555
1. Mamdoh M. Meqdam
Jordan University of Science and Technology, Jordan.
2. Ibrahim R. Thwiny
Buraidah Maternity and Pediatric Hospital,
Al-Qassim, Saudi Arabia.
Dr. Mamdoh M. Meqdam,
Associate Prof. of Virology & Serology,
Department of Applied Biology,
Jordan University of Science and Technology,
P.O. Box: 3030, Irbid-22110,
* Received for Publication: December 6, 2006
* Revision Received: January 22, 2007
* Revision Accepted: July 24, 2007
Acute gastroenteritis continues to be a significant cause of morbidity and mortality worldwide.1 An estimated of more than 700 million cases of acute diarrhea occurred in children under five years of age every year.2 The mortality rate has been estimated to be 3-5 million cases per year, the majority of these which occur in developing countries.3,4
Rotavirus causes more than 130 million episodes of severe diarrhea in children under five years throughout the world.5,6 In developing countries an estimated of 870,000 children die from rotavirus diarrhea each year which reflects an urgent need to develop a vaccine.3 The rate of enteric adenovirus varies from 1-8% in developed countries7,8 to 2-31% in developing countries.9,10 Using enzyme immunoassay and reverse transcription-polymerase-chain reaction recognized calicivirus and especially norovirus as the most common cause of illness with a food origin.11 The rate of detection of astrovirus increased from 1% using electron microscopy12 to 2-13% using monoclonal antibodies in enzyme immunoassays.13
Since most viruses causing gastroenteritis cannot be isolated in cell culture,14 direct visualization in stool specimens by electron microscopy is still the mainstay of diagnosis although it is limited to reference laboratories.15 The introduction of more sensitive techniques for antigen detection in stool based on immunoassay and molecular biology techniques has improved the diagnosis of newly recognized viruses as norovirus and sapovirus.16-19
The present study determined the prevalence of rotavirus and other viruses in children hospitalized with acute gastroenteritis using monoclonal antibodies in enzyme immunoassay kits in association with clinical data from patients.
MATERIALS AND METHODS
Stool specimens: A total of 284 diarrheal specimens were collected from children with gastroenteritis admitted to the Buraidah Maternity and Pediatric Hospital, Al-Qassim, Saudi Arabia during the winter seasons of the years 2004 and 2005. The Buraidah Maternity and Pediatric Hospital is the only and largest specialized hospital in Al-Qassim area. It was established in 2003 with 255 beds. It provides free medical care and serves about 500 patients per day with 12000 deliveries per year of the Buraideh city populations and its suburbs. Information concerning children under study was recorded using a data collection protocol. The collected specimens were stored at -70o C until tested for the viral antigens.
Enzyme immunoassay (EIA) for antigen virus detection: Group A human rotavirus antigen was detected by Rotavirus Screen EIA (Microimmune Ltd, Cat, No. Rota.003, UK). The test employs a monoclonal antibody to the inner capsid protein in rotavirus group A for a capture and detection of the virus.
Adenovirus was detected by Ridascreen Adenovirus (R-Biopharm, Art. No. C 1001, Germany). The test employs a monoclonal antibody directed against the hexon-antigen of adenovirus.
Norovirus (Previously Norwalk-like viruses) was detected by Ridascreen Norwalk-like virus (R-Biopharm, Art. No. C 1401, Germany). The test employs a monoclonal antibody to the specific Norwalk-like virus antigen of the genogroup I and II in stool specimens. Astrovirus was detected by Ridascreen Astruvirus (R-Biopharm, Art. No. C 1301, Germany). The test employs a monoclonal antibody to the specific astrovirus antigen. All assays were run according to the manufacturer’s instructions. Results were spectrophotometrically read at 450 nm. Cutoff values were calculated as specified in the package insert.
Data analysis: Data analysis was carried out using statistical program SPSS version 10.0 for windows (SPSS Inc., Chicago, Illinois, USA). The differences in proportions were compared using a X2-test.
Viruses causing gastroenteritis were detected in 142/284 (50%) of specimens from children admitted to the Buraidah Maternity and Pediatric Hospital, Al-Qassim, Saudi Arabia. Table-I shows the distribution of viruses causing gastroenteritis by age group. Rotavirus (66.2%) was the most common virus, followed by adenovirus (15.5%), norovirus and astrovirus each with 9.2%. In eight specimens, two infected agents were recovered: Rotavirus plus norovirus or adenovirus or astrovirus; adenovirus plus norovirus. Out of 212 of children under than two years of age, 117 (55.2%) children were found positive. Rotavirus was found predominant in this age group (P= 0.032).
The clinical data on children with diarrhea as a result of rotavirus infection are shown in Table II. The results show that children with rotavirus infection are significantly associated with vomiting (72.3%, P<0.001) and dehydration (81.9%, P=0.002).
To our knowledge, this study is the first to investigate the distribution of viruses causing gastroenteritis in Al-Qassim, Saudi Arabia. The prevalence of rotavirus disease is similar in children in both developed and developing countries. However, children in developing countries die more frequently, possibly due to poorer access to hydration therapy and prevalence of malnutrition.20
Although the viral diarrhea as a major cause of morbidity and mortality in developing countries is well recognized,21-24 there are few reports which document the viral gastroenteritis in Saudi Arabia.25-27 The present study showed that the overall rate of infection with viruses causing gastroenteritis was 142/284 (50%). As has been found previously in many studies,21-23, 28 rotavirus was the most causative agent of acute gastroenteritis in children. Our result reinforced the previous results that rotavirus is responsible for 20-60 per cent of severe diarrheal illness requiring hospitalization in infants and young children in developed as well as in developing countries.21,22,29
Fecal adenovirus infection is probably the second most common cause of gastroenteritis in children associated with diarrhea as reported in several countries.23,25,29-31 In the present study adenovirus was detected in 15.5 per cent.
The introduction of enzyme immunoassay (EIA) as a rapid, sensitive, and specific viral diagnostic technique for the diagnosis of rotavirus, adenovirus, norovirus, and astrovirus has led to increased detection of these viruses and, therefore, physicians will be able to make more accurate treatment decisions, reduce unnecessary antibiotic treatment, and isolate patients to reduce nosocomial spread.20 Previously, since most viruses causing gastroenteritis cannot be isolated in cell culture, direct visualization of them by electron microscopy was the mainstay of diagnosis. The EIA used in this study employs a genus-specific monoclonal antibody to detect a specific viral antigen in the virus.
Commercial EIA and reverse transcription-polymerase chain reaction have also been adapted for the detection of norovirus and astrovirus. Since the introduction of these tests, the viruses have been recognized significantly as a cause of diarrhea in infant and young children. In community, astrovirus is responsible for 2-13 percent of cases that need hospitalization.7,8,28,32 The prevalence of norovirus and astrovirus in this study is similar to the rate measured previously in hospitalized children.
In both developed and developing countries, about 90% of infants by the age of three years, develop rotavirus infection.33 EIAssouli et al., reported that the rotavirus group A was common in the first two years of life in Saudi children with a peak in children aged 2-12 months.27 In Oman, Aithala et al., reported that most infection with rotavirus was in children less than two years old.24 In the present study, our results are in consistence with these results and others22,23,30,31 as this age group was significantly related to infection with rotavirus group A (P=0.032).
Bern et al., reported that rotavirus group A was significantly associated with watery diarrhea in Bangladesh.34 In this study 41 per cent of the patients had watery diarrhea (results not shown). In parallel with Collier et al.35 results, in the current study most of the patients had symptoms for less than five days. Concerning the other clinical symptoms, it has been reported that vomiting, dehydration, and fever are the most common clinical symptoms shown in patients with rotavirus infection.23,29,36 Modarres et al., reported that most children with rotavirus infection had vomiting (86.7%), and dehydration (87.8%).37 In this study, rotavirus group A infection was significantly associated with vomiting (P< 0.001) and dehydration (P=0.002). However, in the present study, there was no difference in diarrhea and fever (P=0.422), diarrhea and weakness (P=0.355) or diarrhea and abdominal pain (P=0.268) in patient infected with rotavirus group A. Similar results were reported by Bon et al.28
The introduction of the two new rotavirus vaccines, RotaTeq and Rotarix that are currently in the late stage of development, will hopefully protect children against the numerous rotavirus serotypes that are currently predominant.38,39
The authors acknowledge Dr. Zaidan Jassem for his critical review of the manuscript.
1. Madeley CR, Cosgrove BP. 28nm particles in faeces in infantile gastroenteritis. Lancet 1975;2:451-2.
2. Synyder JD, Merson MH. The magnitude of the global problem of acute diarrhoeal disease: A review of active surveillance data. Bull WHO 1982;60:605-31.
3. Guerranrt RI, Hughes JM, Lima NL, Crane J. Diarrhea in developed and developing countries: Magnitude, special settings, an etiology. Rev Infect Dis 1990;S41-50.
4. Warren KS. Tropical medicine or tropical health. The Health Clark Lectures 1988. Rev Infect Dis 1990;12:142-56.
5. Glass RI, Gentsch J, Smith JC. Rotavirus vaccines: Success by reassortment. Science 1994;265:1389-91.
6. Glass RI, Bresee JS, Parashar UD, Holman RC, Gentsch JR. First rotavirus vaccines licenced: Is there really a need? Acta Paediatr Suppl 1999;88:2-8.
7. Bon F, Fascia P, Dauvergne M, Tenenbaum D, Planson H. Prevalence of group A rotavirus, human calicivirus, astrovirus, and adenovirus type 40 and 41 infection among children with acute gastroenteritis in Dijon, France. J Clin Microbiol 1999;37:3055-8.
8. Grimwood K, Carzino R, Narnes GL, Bishop RF. Patients with enteric adenovirus gastroenteritis admitted to an Australian pediatric teaching hospital from 1981 to 1992. J Clin Microbiol 1995;33(1):33-6.
9. Cruz JR, Caceres P, Cano F, Flores H, Bartlett A, Torun B. Adenovirus types 40 and 41 and rotaviruses associated with diarrhea in children from Guantemala. J Clin Microbiol 1990;28:1780-4.
10. Qiao H, Nilsson M, Abreu ER. Viral diarrhea in children in Beijing, China. J Med Virol 1999;57:390-6.
11. Nakata S, Honma S, Numata KK, Kogawa K, Ukae S. Members of the family Caliciviridae (Norwalk virus and Sapporo virus) are the most prevalent cause of gastroenteritis outbreaks among infants in Japan. J Infect Dis 2000;181:2029-32.
12. Lew JF, Glass RI, Petric M, Labaron CW, Hammond GW. Six year retrospective surveillance of gastroenteritis viruses identified at ten electron microscopy centers in the United State and Canada. Pediatr Infect Dis J. 1990;9:709-14.
13. Mustafa H, Palombo EA, Bishop RF. Epidemiology of astrovirus infection in young children hospitalized with acute gastroenteritis in Melbourne, Australia, over a period of four consecutive years, 1995 to 1998. J Clin Microbiol 2000;38:1058-62.
14. Hedberg CW, Osterholm MT. Outbreaks of food-borne and waterborne viral gastroenteritis. Clin Microbiol Rev 1993;6:199-210.
15. Donelli G, Superti F, Tinari Ak, Marziano ML, Caione D, Concato L, et al. Viral childhood diarrhoea in Rome: A diagnostic and epidemiological study. Microbiologica 1993;16:215-26.
16. Thornton AC, Jenning-Conklin KS, McCormick MI. Noroviruses: agents in outbreaks of acute gastroenteritis. Disaster Management and Response 2004;2(1):4-9.
17. Lopman B, Vennema H, Kohli E, Pothier P, Sanchez A. Increase in viral gastroenteritis outbreaks in Europe and epidemic spread of new norovirus variant. Lancet 2004;363(9410):682-8.
18. Gallimore CL, Pipkin C, Shrimpton H, Green AD, Pickford Y. Detection of multiple enteric virus strains within a foodborne outbreak of gastroenteritis: An indication of the source of contamination. Epidemiol Infect 2005;133(1):41-7.
19. Carmelann Z, Bok K, Parada E, Barnes M, Tomas B. Prevalence and genetic characterization of caliciviruses among children hospitalized for acute gastroenteritis in the United States. Infection, Genetics and Evolution 2005;5(3):281-90.
20. Parashar UD, Hummelman EG, Bresee JS, Miller MA, Glass RI. Global illness and deaths caused by rotavirus disease in children. Emerg Infect Dis 2003;9(5):565-72.
21. Giordano MO, Ferreyra LJ, Isa MB, Martinez LC, Yudowsky SI, Nates SV. The epidemiology of acute virual gastroenteritis in hospitalized children in Cordoba city, Argintina: An insight of disease burden. Rev Inst Med trop S Paulo 2001;43(4):193-7.
22. Meqdam MM, Shdiafat AAS, Malkawi HI. Prevalence and characteristics of rotavirus group A causing gastroenteritis in Northern Jordan. Singpore Paediatr J 2001;43(1):10-7.
23. Meqdam MM, Yousef MT, Nimri LF, Shurman AA, Rwashdeh MO, Al-Khdour MS. Viral gastroenteritis among young children in Northern Jordan. J Trop Pediatr 1997;43:349-52.
24. Aithala G, Al-Dhahry SHS, Saha A, Elbualy MS. Epidemiological and clinical features of rotavirus gastroenteritis in Oman. J Trop Pediatr 1996;42:54-7.
25. ElAssouli SM, Mohammed KA, Banjar ZM. Human rotavirus genomic RNA electropherotypes in Jeddah, Saudi Arabia from 1988 to 1992. Ann Trop Pediatr 1995;15:45-3.
26. ElAssouli SM, Banjar ZM, Mohammed KA, Zamajhchari FT. Rotavirus infection in children in Saudi Arabia. Am J Trop Med Hyg 1992;46:272-7.
27. ElAssouli SM, Banjar ZM, Mohammed KA, Milaat WA, ElAssouli MZ. Genetic and antigenic analysis of human rotavirus prevalent in Al-Taif, Saudi Arabia. J Trop Pediatr 1996;42:211-9.
28. Bon F, Fascia P, Dauvergene M, Tenenbaum D, Planson H, Petion AM, et al. Prevalence of group A rotavirus, human calicivirus, astrovirus, and adenovirus type 40 and 41 infections among children with acute gastroenteritis in Dijon, France. J Clin Microbiol 1999;3(9):3055-8.
29. Bresee JS. Widdowson MA, Monroe SS, Glass RI. Foodborne viral gastroenteritis: Challenges and opportunities. Clin Infect Dis 2002;35:748-53.
30. Wadell GA, Allard A, Johansson M, Svensson L, Uhnoo I. Enteric adenoviruses. John Wiley & Son, Inc., Chichester, United Kingdom, 1987;73-91.
31. Kim KH, Yang JM, Joo SI, Cho YG, Glass RI, Cho YA. Importance of rotavirus and adenovirus type 40 and 41 in acute gastroenteritis in Korean children. J Clin Microbiol 1990;28:2279-84.
32. Hansman GS, Katayama K, Maneekarn N, Peerakome S, Khamrin P. Genetic diversity of norovirus and sapovirus in hospitalized infants with sporadic cases of acute gastroenteritis in Chiang Mai, Thailand. J Clin Microbiol 2004;42(3):1305-7.
33. Kapikian AZ, Chanock RM. Rotaviruses. In: Fields BN. Knipe RM, Chanock MS, Hirsch JL, Melnick TP, Monath B, Roizman (editors), Virology. 2nd ed., Raven Press, New York, (1990):1353-1403.
34. Bern C, Unicomb L, Gentsch JR, Banul N, Yunus M, Sack RB,et al. Rotavirus diarrhea in Bangladeshi children: Correlation of disease severity with serotypes. J Clin Microbiol 1992;30:3234-8.
35. Collier L, Oxford J. Human virology: A text for students of medicine, dentistry, and microbiology. Oxford University Press, Oxford, (1993), 400.
36. Staat MA, Azimi PH, Berke T, Roberts N, Bernstein DI. Clinical presentation of rotavirus infection among hospitalized children. Pediatr Infect Dis J 2002;21:221-7.
37. Modarres S, Modarres S, Oskoii NN. Rotavirus infection in infants and young children with acute gastroenteritis in the Islamic Republic of Iran. Eastern Mediterranean Health J 1995;1:210-4.
38. Vesikari T, Karvonen A, Puustinen L, Zeng SQ, Czakal ED. Efficacy of RIX 4414 live attenuated human rotavirus vaccine in finnish infants. Pediatr Infect Dis J 2004;23:937-43.
39. De Vos B, Vesikari T, Linhares AC, Salinas B, Perez-Schael l. A rotavirus vaccine for prophylaxis of infants against rotavirus gastroenteritis. Pediatr Infect Dis J 2004;23:S179-82.
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