Study of clinical profile of rotaviral gastroenteritis among patients admitted in a tertiary care hospital

Original Article

Study of clinical profile of rotaviral gastroenteritisamong patients admitted in a tertiary care hospital

Kochurani Abrahama, Sanjay Bafna b,*, Leena Hiremath c, Shailesh Muley d

aSenior Registrar, Dept of Paediatrics, Jehangir Hospital (Apollo Group Hospital), Pune, Indiab Senior Consultant Paediatrician, HOD, Dept of Paediatrics, Jehangir Hospital (Apollo Group Hospital), Pune, IndiacSenior Consultant Paediatrician, Dept of Paediatrics, Jehangir Hospital (Apollo Group Hospital), Pune, IndiadDNB Resident, Dept of Paediatrics, Jehangir Hospital (Apollo Group Hospital), Pune, India

a r t i c l e i n f o

Article history:

Received 19 October 2013

Accepted 14 February 2014

Available online 15 March 2014

Keywords:

Rotavirus

Gastroenteritis

Infants

Dehydration

a b s t r a c t

Objectives: To study the incidence and clinical profile of rotaviral gastroenteritis (RVGE)

among patients admitted with acute gastroenteritis (AGE) in Jehangir hospital.

Methods: 75 children aged 1month to 5 years admitted with AGE during Jan 2012 to July 2013

were studied. Detailed history and clinical profile were documented. Their stool samples

were sent for routine examination, rotaviral and adenoviral studies by immunochroma-

tographic test.

Results: We studied 75 children with AGE, of which, 27 (36%) were positive for rotavirus and

6 (8%) for adenovirus.

Out of the 27 rotaviral diarrhea patients, 15 (55.5%) were infants, 10 (37%) were between

1 and 3 years and 2 (7.4%) were in 3e5 age group.

There was clustering of cases in the first quarter of the year without any remarkable

seasonal variability.

The average duration of rotaviral diarrhea was 4.7 days and average hospital stay was

about 3.8 days. None of these RVGE patients progressed to persistent diarrhea or required

hospitalization beyond 7 days.

The common presenting features were vomiting, loose motions and fever. The degree of

dehydration was mild in all patients.

Conclusion: This study documents the high incidence of rotaviral diarrhea in our popula-

tion. It also highlights the fact that rotaviral diarrhea predominantly occurs in younger

children, particularly infants. Early health care access and good nutritional status probably

accounted for the mild disease in our population.

Copyright ª 2014, Indraprastha Medical Corporation Ltd. All rights reserved.

1. Introduction

Globally diarrhea is major cause of morbidity and mortality in

children under 5 years.1 Diarrhea is third leading killer of in-

fants and under five children in India and is responsible for

13% deaths in this age group.2

* Corresponding author. Dept of Paediatrics, Jehangir Hospital(Apollo Group Hospital), 32, Sassoon Road, Pune 411001, India.Tel.: þ91 9823005044.

E-mail address: sanjaybafna16@gmail.com (S. Bafna).

Available online at www.sciencedirect.com

ScienceDirect

journal homepage: www.elsevier .com/locate /apme

a p o l l o m e d i c i n e 1 1 ( 2 0 1 4 ) 2e5

http://dx.doi.org/10.1016/j.apme.2014.02.0030976-0016/Copyright ª 2014, Indraprastha Medical Corporation Ltd. All rights reserved.

Rotavirus is the major cause of severe gastroenteritis in

infants and young children worldwide. It is estimated that

rotavirus disease is responsible for more than half million

deaths annually among under five children. Majority of these

deaths occur in developing countries.1

Rotavirus is leading cause of severe diarrhea in Indian

children under 5 years and has been projected to cause large

number of hospitalizations and 1.22e1.53 million deaths

annually.3

Unlike many other pathogens, the proportion of diarrhea

caused by rotavirus does not vary widely between developed

and developing countries.4 However there are significant dif-

ferences like age of first infection, serotypes, seasonality and

severity of the disease.5,6

We studied the incidence and clinical profile of rotavirus

gastroenteritis admitted in our hospital.

2. Methodology

2.1. Study site

This study was conducted in Jehangir hospital (Apollo group

hospital), Pune which is a tertiary care hospital catering

mainly to middle and upper middle class urban population.

2.2. Enrollment criteria

All children less than 5 years who were admitted in our hos-

pital with acute gastroenteritis (AGE) from Jan 2012 to July

2013 were enrolled.

Children with bacillary dysentery, chronic diarrhea and

immunodeficiency were excluded.

2.3. Clinical assessment

Detailed history and clinical profile were documented as per

the proforma. Details of onset, frequency and duration of

diarrhea, and other symptoms like fever, vomiting were

recorded. Degree of dehydration and treatment details were

recorded. Nutritional assessment was done by weight for age

using WHO (World Health Organization) growth charts and

IAP (Indian Academy of Paediatrics) classification for assess-

ment of nutritional status. Stool sampleswere sent for routine

examination, rotaviral and adenoviral studies by immuno-

chromatographic test (RIDA QUICK Rotavirus/Adenovirus

Combi kit). All stool samples were transported to laboratory

within 2 hours and kept at 4 �C until testing. Other in-

vestigations were done as required.

3. Results

75 children were admitted with acute gastroenteritis out of

which 27 (36%) were positive for rotavirus and 6 (8%) for

adenovirus (Fig. 1).

Out of 27 patientswith rotaviral diarrhea 15 (55.5%)were<1

year, 10 (37%) were between 1 and 3 years and 2 (7.4%) were in

3e5 years age group. Amongst them, 18.5% were less than 6

months (Fig. 2).

Of the 27 children with rotaviral gastroenteritis, 16 (59.2%)

were boys and 11 (42.5%) were girls.

There was clustering of cases in the months of January

(14.8%), February (14.8%) and March (29.62%). During rest of

the year, distribution of cases was similar (Fig. 3).

All children were well nourished except one child who had

grade I malnutrition.

The average duration of diarrhea in rotavirus positive

children was 4.7 days and their average duration of hospital

stay was about 3.8 days. None of them progressed to persis-

tent diarrhea or required hospitalization beyond 7 days.

Patients presented with fever, loose motion, vomiting or

combination of these. Out of the 27 children, 12 (44.44%) pre-

sentedwith fever, loosemotions and vomiting, 7 (25.92%)with

loose motions and vomiting, 7 (25.92%) with loose motions

and fever and 1 (3.7%) with only loose motions (Fig. 4).

Degree of dehydration was mild in all children.

4. Discussion

Rotavirus is an icosahedral RNA virus. Seven serogroups have

been described (AeG). Group A rotaviruses causemost human

disease (Fig. 5). Rotavirus is composed of 3 concentric protein

shells surrounding the genome. The outermost layer of virus

is composed of two surface proteins VP7 which determines

the G serotype and VP4 which determines the P serotype. Each

rotavirus strain is designated by its G serotype number fol-

lowed by P serotype number.7

Fig. 1 e Incidence of rotaviral gastroenteritis in study site.

Fig. 2 e Agewise incidence of rotavirus gastroenteritis in

study site.

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There is wide variation in the strains causing rotavirus

disease worldwide. Rotavirus isolates from India are geneti-

cally heterogenous.8,9 The study done by Indian Rotavirus

Strain Surveillance Network found that there is significant

diversity in rotaviral strains causing RVGE in Indian

population.10

In our study, the rotavirus was detected in 36% of all under

five children admitted for gastroenteritis. Various studies have

looked at the contribution of rotavirus to severe diarrhea in

India.11e13 Review of 30 such studies done from 1976 to 1996

showed thatnearly 18%of themweredue to rotavirus andmore

recent reviews of 10 studies from 1999 to 2004 showed an inci-

dence of 23.4% of rotaviral diarrhea in children admitted with

gastroenteritis.13Amulticentrehospitalbasedstudyof rotaviral

disease done by Kang et al in Indian children reported 39%

incidence among under five children admitted for gastroen-

teritis.10 2008 Asia Rotavirus Surveillance Network (ARSN) data

from India shows that rotavirus contributes to as high as 39%of

all cases causing diarrhea needing hospitalizations.14

It indicates that rotavirus is emerging as a leading cause of

severe diarrhea as other etiological agents are controlled by

better nutrition and hygiene. Improvement in sanitation and

hygiene had a tremendous impact on diarrheal disease due to

bacteria and parasites but less so on RVGE. This is because of

the persistence of rotavirus in high income settings and is

thought to be due to transmission through person-to-person

contact which persists even as fecal-oral transmission

diminishes.15

The study also documents early incidence of rotavirus

disease in India. In our study highest percentage of patients

were infants (55.5%) and 18.5% children were less than 6

months.

92% of the children were under 3 years. These results are

similar to the findings from various Indian studies.

Kang et al in India reported high incidence of rotavirus

disease in the early age group.10 Study done by Velazquez et al

also reported that majority (96%) of infections occur below 2

years and that subsequent infections were milder.16

Most of the rotavirus gastroenteritis in India occurs in first

2 years of life .In hospital based studies 87% of all rotaviral

cases occurred by 18 months of age.17e20 Additionally only

13% cases were in children less then 6 months. However,

outpatient and community based studies found higher pro-

portion of cases (30%) in children less than 6 months.18,21 This

difference is likely to be function of severity as in young

children, infection may be attenuated by maternal antibodies

and thus, severe disease is uncommon.

These findings have clear implication for vaccination as

immunity will need to be induced early in children in devel-

oping countries for effective protection against RVGE.

Most Indian studies have observed a seasonal variation

with more cases in winter months throughout the coun-

try.17,19,22 Studies in Pune and Chennai have observed sea-

sonal variation despite their tropical climates.17,19 In our

study there was clustering of cases in early quarter of the

year, however definite seasonal pattern could not be

documented.

The clinical features of rotavirus diarrhea in our study

matched those reported in the longitudinal cohort study in

Fig. 3 e Graph showing month wise distribution of cases in

study site.

Fig. 4 e RVGE-presenting complaints.

Fig. 5 e Rotavirus virion.

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Egypt.23 It was difficult to differentiate rotavirus infection

from non-rotavirus gastroenteritis from clinical features

alone. Apart from diarrhea, majority of patients (70%) had

vomiting as the initial presentation. Vomiting is probably

caused by stimulation of chemoreceptors in upper gastroin-

testinal tract that may be activated by contraction or disten-

tion of gut or by physical damage.

Over a period of 1e2 days, viral replication and infection

spreads further along the small intestine. Mucosal lesions are

produced as a result of selective destruction of tips of villi

lining the gut. This results in watery diarrhea and dehydra-

tion. Diminished disaccharidase activity leads to malabsorp-

tion.5,7 Majority of our children had disease duration of less

than a week though in severe cases fever, vomiting and

diarrhea are known to persist longer.24,25

Though RVGE is the major cause of severe dehydrating

diarrhea; surprisingly most of our children had mild dehy-

dration and had mild disease. This might be because of early

health care access and good nutritional status of our study

population.

In summary, this study highlights the high prevalence of

rotaviral diarrhea in our population. The study also docu-

ments that majority of rotaviral diarrhea occur in infancy

signifying the importance of early rotaviral vaccination. Early

health care access and rehydration reduces morbidity and

mortality associated with rotaviral gastroenteritis.

Conflicts of interest

All authors have none to declare.

Acknowledgments

Dr Vikram Padbidri, Consultant Microbiologist, Dept. of

Microbiology, Jehangir Hospital, Pune.

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