pediatric viral gastroenteritis during eight years pediatric viral gastroenteritis 73 70-60-50-a `...
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Vol. 18, No. 1JOURNAL OF CLINICAL MICROBIOLOGY, JUlY 1983, P. 71-78 0095-1137/83/070071-08$02.00/0 Copyright © 1983, American Society for Microbiology
Pediatric Viral Gastroenteritis During Eight Years of Study CARL D. BRANDT,12t* HYUN WHA KIM, 1'2 WILLIAM J. RODRIGUEZ, 1'2 JULITA 0. ARROBIO,' BARBARA C. JEFFRIES,1 EMMA P. STALLINGS,1 CAROLYN LEWIS,1 AUDREY J. MILES,1
ROBERT M. CHANOCK,2'3 ALBERT Z. KAPIKIAN,2'3 AND ROBERT H. PARROTT2 Research Foundation of Children's Hospital National Medical Center' and Department of Child Health and Development, George Washington University School of Medicine and Health Sciences,2 Washington, D.C.
20010; and Laboratory of Infectious Diseases, National Institute of Allergy and Infectious Diseases, Bethesda, Maryland 202053
Received 22 December 1982/Accepted 25 March 1983
During the period January 1974 through July 1982, fecal samples from 1,537 pediatric inpatients with gastroenteritis were tested for enteric viruses by electron microscopic and rotavirus enzyme-linked immunosorbent assay techniques. Rota- viruses were detected in 34.5% of these patients, enteric adenoviruses were detected in 4.7%, -27-nm viruses were detected in 1.6%, and at least one of these agents was found in 40.1% of the study subjects. Three infections were by an apparently new agent which morphologically is a rotavirus, but which failed to react in the rotavirus enzyme-linked immunosorbent assay. During the first 8 calendar years of study, rotaviruses were detected in 39.0% of 577 patients in the even-numbered years and 30.3% of 702 patients in the odd-numbered years. Adenoviruses were found in all calendar months. Rotaviruses were found in inpatients in November through July, whereas -27-nm viruses were found in October through June. The percentage of patients who had a demonstrated viral infection rose steadily from 7.4% in September to 72.0% in January and then steadily declined to 2.9% in August. Viral infection was especially common in study subjects who were 7 through 24 months of age; 61% of such children had one or more enteric viruses. Rotavirus-infected patients tended to be younger during the months of greatest rotavirus activity than at the beginning and end of the rotavirus season, presumably because of a greater exposure to virus at the height of the rotavirus outbreak.
In recent years, previously unrecognized rota- viruses, adenoviruses, and miscellaneous, most- ly small (-27-nm) viruses have been detected and associated with gastroenteritis (5, 8, 12, 13, 16, 17, 19, 21, 23, 27, 29; M. Santosham, R. Yolken, C. Stockton, L. Benson, and R. Black, Program Abstr. Intersci. Conf. Antimicrob. Agents Chemother. 22nd, abstr. no. 897, 1982). Published studies tend to describe the epidemi- ology of these agents during relatively brief study periods and thus do not fully reflect the occurrence of long term trends and variations. This report amplifies on certain of our previous observations with these agents (2, 3, 5, 12, 23) and concentrates on epidemiologic patterns of infection in infants and young children with acute gastroenteritis during 96 consecutive months of study. By virtue of the great impor- tance of rotaviruses as a cause of pediatric gastroenteritis, this paper especially emphasizes findings relevant to rotavirus infection.
t Reprint requests should be directed to C. D. Brandt, Research Foundation of Children's Hospital National Medical Center, 111 Michigan Avenue, N.W., Washington, DC 20010.
MATERIALS AND METHODS The study population included most infants and
young children who were hospitalized at Children's Hospital National Medical Center with diarrhea or vomiting (or both) of 4 days' duration or less, begin- ning on 16 January 1974. Diagnostic fecal samples from these patients generally were obtained on the first or second hospital day. Stools and diaper scrap- ings and some rectal swab specimens usually were tested for viruses by direct electron microscopy (EM) (3). Specimens negative or untested by direct EM were tested by immune EM (IEM) (3, 13). In addition, all specimens were tested by a sensitive rotavirus group- specific enzyme-linked immunosorbent assay (ELISA) procedure (3, 13). Additional details of our study methods and findings have been presented else- where (2, 3, 5, 12, 23).
RESULTS Overview of virus detection. In the period
January 1974 through July 1982, one or more fecal samples from 1,537 pediatric patients who were hospitalized with acute gastroenteritis at this medical center were tested for enteric virus- es by EM and rotavirus ELISA techniques.
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72 BRANDT ET AL.
Overall, rotaviruses were detected in 530 (34.5%) of the study patients, adenoviruses were detected in 73 (4.7%), -27-nm viruses were detected in 24 (1.6%), and at least one of these agents was detected in 616 (40.1%) of the total group of gastroenteritis patients.
All inpatients who were found rotavirus posi- tive by the ELISA also were found (after some retesting and a few lengthy EM readings) to be rotavirus positive by EM or IEM. Specimens from two study patients in February 1981 and another in March 1982 contained particles which morphologically were rotaviruses (and were counted as rotaviruses for the purposes of this paper), but which repeatedly failed to react to ELISA positivity for rotavirus.
In the remainder of this paper, unless other- wise noted, data will be presented for the 8 calendar years from January 1974 through De- cember 1981.
Enteric viruses by calendar year. On a yearly basis, between 28.8 and 43.1% of all gastroenter- itis inpatients studied were rotavirus positive, 1.4 to 10.7% were adenovirus positive, 0 to 4.9% were -27-nm virus positive, and at least one of these agents was present in 33.7 to 48.6% of all gastroenteritis inpatients tested (Table 1). A type of periodicity is evident in Table 1, in
that in each of the odd-numbered calendar years, the percentage of gastroenteritis inpa- tients with a rotavirus infection was lower than in the preceding even-numbered year. Overall, there was a statistically significant excess of rotavirus infections (39.0 versus 30.3%) and total virus infections (44.5 versus 37.0%) in the even-numbered calendar years as compared with the odd-numbered calendar years. A nearly significant excess of -27-nm virus infections
was also seen in the even-numbered calendar years. Adenovirus infections were increased, but not significantly so, in the odd-numbered years.
Enteric viruses by month. The regularity of the annual waves of rotavirus infection in this locale can be seen in Fig. 1, which includes data through July 1982. Rotavirus infections were detected in inpatients during 55 (53%) of the 103 illustrated months, and as many as 39 patients were hospitalized with rotavirus infection in one study month (January 1981). Among all individ- uals tested (including children and adults not otherwise described in this paper) rotaviruses were first detected each year between 22 Octo- ber and 22 December, their activity peaked in January or February, and these viruses last were seen between 25 April and 16 July. Rotaviruses were never found in inpatients in August, Sep- tember, or October and were seen in July only in 1982. Although not shown in Fig. 1, adenovirus- es were detected in from one to five inpatients during 47 (46%) of the 103 illustrated months, whereas -27-nm viruses were found in from one to three inpatients in 20 (19%) of these study months. When data from the first 96 months of study
were combined, the proportion of gastroenteritis inpatients in whom an enteric virus was demon- strated by EM, IEM, or rotavirus ELISA rose steadily from 7.4% in September to a peak of 72.0% in January and then steadily declined to 2.9% in August (Table 2). Over two-thirds of all gastroenteritis patients in January were rota- virus positive, and more than two-thirds of the detected rotavirus infections occurred in Janu- ary and February. Adenovirus infections were found year round, but were least evident in
TABLE 1. Virus infections in gastroenteritis inpatients during 8 successive years'
No. No. (%) with indicated infectionCalendar year tetd°2-mlCalendaryeartested Rotavirus Adenovirus v27-n Totaib
1974 80 32 (40.0) 3 (3.8) 0 (0.0) 34 (42.5) 1975 103 34 (33.0) 11 (10.7) 2 (1.9) 45 (43.7) 1976 144 62 (43.1) 2 (1.4) 7 (4.9) 70 (48.6) 1977 153 44 (28.8) 10 (6.5) 0 (0.0) 54 (35.3) 1978 166 62 (37.3) 10 (6.0) 4 (2.4) 73 (44.0) 1979 175 51 (29.1) 6 (3.4) 2 (1.1) 59 (33.7) 1980 187 69 (36.9) 10 (5.3) 4 (2.1) 80 (42.8) 1981 271 84 (31.0) 15 (5.5) 4 (1.5) 102 (37.6)
Odd-year total 702 213 (30.3)c 42 (6.0) 8 (1.1)d 260 (37.0)e Even-year total 577 225 (39.0)c 25 (4.3) 15 (2.6)d 257 (44.5)e Overall total 1,279 438 (34.2) 67 (5.2) 23 (1.8) 517 (40.4)
a The study began on 16 January 1974. b Total with at least one infection; dual infections account for mathematic discrepancies. C 2 = 10.5, P < 0.005. d x2 = 3.82, P = 0.051. e x2 = 7.4, P < 0.01.
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PEDIATRIC VIRAL GASTROENTERITIS 73
10 E 30- E z
* = Rotavirus Positive O = Rotavirus Negative
ol~~~~~~~~~~~~~rJ.LLLLWIUELJL.LL LL MLLL-L LL...1 974 1 1975 1 1976 1977 l 1978 1981 1 1982
July 1982 (as
FIG. 1. Rotavirus infections in patients with gastroenteritis from January 1974 through dem