Rotavirus Gastroenteritis FMS

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Facts on Rotavirus Enteritis

Dr Nazrul Neezam

Paediatric GastroenterologistPaediatric Institute, HKL


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Introduction

First isolated in 1973 in Australia by

Ruth Bishop at the Royal Children's

Hospital in Melbourne

EM identification from duodenalbiopsies from children with diarrhea.

"Virus particles in epithelial cells of

duodenal mucosa from children with

acute non-bacterial gastroenteritis,"Lancet, 1:1281-3, 1973

Rota wheel

Reoviridae family


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Introduction

Cause more severe and acute diarrhea in children:

111 millions of cases require ambulatory care

25 millions of medical consultations

2 millions of hospitalized patients

From 352,000 to 592,000 deaths of children.


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61 dot = 250 deaths

Global Distribution of 527,000 Annual

Rotavirus Deaths in Young Children

Parashar et al, JID, 2009


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We do have Rotavirus deaths

10 cases of acute diarrheal deaths among 4689 admitted to an urban

hospital over the period of 15 years

Lee et al. Deaths following acute diarrhoeal diseases among hospitalised infants in Kuala

Lumpur Med J Malaysia 1999; 54:303-9

Based on an estimated 2.5 deaths/100,000 children, authors estimated

that each year, there would be 34 children died of RV-A infection

Hsu et al. Estimates of the burden of rotavirus disease in Malaysia. J Infect Dis 2005;

192(Suppl 1):S80-6

Another nationwide study on the under-5 mortality in 2006, involving all

government hospitals and rural health centers, showed that a total of 320

deaths were classified under certain infectious and parasitic diseases and89 of these deaths were attributable to acute diarrheal disease

Wong SL, Hussain IMI. A study on under five deaths in Malaysia in the year 2006.

Clinical Research Centre, Kuala Lumpur, 2008


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Wong SL, Hussain IMI. A study on under five deaths in Malaysiain the year 2006. Clinical Research Centre, Kuala Lumpur, 2008


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Important aetiology of severe diarrhea in less

than 5 yrs

Other

OtherBacterial

Bacterial

Rotavirus

Developed Countries Developing Countries

Unknown Unknown Rotavirus

A. Kapikian, Fields Virology 2003


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Seasonality patternPatel et al. Global seasonality of Rotavirus disease. The Pediatric Inf Dis Journal 32(4) April 2013


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In Malaysia..

AGE is the most common indication of hospital admission

Rotavirus the most common identifiable enteropathogen,both in the community and in those who required hospadmission with estimated 8571 admissions yearly.

High morbidity with rotavirus infection ie. about half of thoseadmitted had moderate to severe dehydration

Hsu VP, Abdul Rahman H, Wong SL, et al. Estimates of the burden ofrotavirus disease in Malaysia. J Infect Dis 2005;192(Suppl. 1):S806.


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Hsu VP, Abdul Rahman H, Wong SL, et al. Estimates of the burden of

rotavirus disease in Malaysia. J Infect Dis 2005;192(Suppl. 1):S806.


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ctd

Significant financial burden with median direct cost of hospadmission to manage rotavirus AGE is estimated to be 211.91USD

Hence yearly cost of managing in patient rotavirus AGE is

estimated to be 1.8 million USD Cost would be much higher if outpatient visits, non medical

costs are included

Lee WS, Poo MI, Nagaraj S. Estimates of economic burden of providinginpatient care in childhood rotavirus gastroenteritis from Malaysia. JPaediatr Child Health 2007;43:818-25.


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ctd

Lee WS, Poo MI, Nagaraj S. Estimates of economic burden of

providing inpatient care in childhood rotavirus gastroenteritis

from Malaysia. J Paediatr Child Health 2007;43:818-25


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Transmission route

Fecal oral Person to person,

Foods,

Food handlers,

Fomites survives many days in the environment Airway has been suggested due to

- High rates of infection during first 3 yrs of life regardless ofsanitary conditions

- Failure to document fecal oral transmission in several

outbreaks- Dramatic spread over large geographic areas during winter

UD Parashar. CDC Atlanta, USA


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Clinical course of infection

Incubation period 1 3 days

Sudden onset (6 days): Vomiting disappear in 24-48 hours

Fever Profuse watery diarrhea

Dehydration

Encephalopathy / Encephalitis reported

Contagiousness 8 days

>30 days in immunocompromised


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Management

General principles :

- Identification of children at risk of complication

- Prevention / correction of dehydration and electrolyteimbalance

- Supplementary / adjuvant pharmacotherapy

- Provision of adequate and appropriate nutrition


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Oral rehydration

NO SIGNS OF DEHYDRATION Home management if no excessive vomiting

Continue usual feeding practice

Normal diet

ORS 10 mls/kg per purge

SOME SIGNS OF DEHYDRATION Needs replacement with 30-90 mls/kg of ORS

within 2-3 hrs

Followed by ORS 10 mls/kg per purge

Small frequent feeds with reassessment

Intravenous fluids if fails oral rehydration

SEVERE DEHYDRATION Intravenous fluids with or without fluid

boluses depending on situation

Oral rehydration to be encouraged


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When oral rehydration fail:

In about 5% of children the signs of dehydration do not improve during ORT, or

they worsen after initial improvement. The usual causes are :

Continuing rapid stool loss ( > 15-20ml/kg/hour )

Insufficient intake of ORS solution owing to fatigue or lethargy

Frequent , severe vomiting

Treatment :

Give ORS solution by nasogastric tube

Or

IV fluids (amount to be given depend on the degree of dehydration)

Oral rehydration


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Nutrition

Issues regarding nutrition

- When to refeed ?

- To dilute or not to dilute ?- Specialized formula ?

- Use of zinc supplements ?


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Nutrition

When to refeed ?

- As tolerated, no specific withdrawal period. Should not bewithdrawn longer than 4-6 hrs after rehydration.

- Breast feeding and formula feeding to be continued.


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Nutrition

To dilute or not to dilute ?

- No evidence to support dilution of formula during AGEepisode.

- During acute phase, diarrhea is as a result of combined

secretory and osmotic hence slight reduction of stool output isexpected. However, the duration of diarrhea remains thesame.

- Will affect the nutritional status whereby patients on dilutedformula take longer time to regain their weight.

Brown et al. Use of non human milks in the dietary management of

young children with acute diarhea : a meta analysis of clinical trials.

Pediatrics 1994;93:17-27


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Nutrition

Soy formula ? Lactose free formula ? Extensively hydrolyzed

formula ? Elemental formula ?

- No specific indication to empirically start with these formulas

during acute phase.

- Soy or lactose free formulas can be considered if suspected to

have secondary lactose intolerance. (soy not recommended

for infants less than 6 mths old)

- Extensively hydrolyzed formula (ailementum) / elemental

formula (neocate / comidagen) are reserved for suspected

secondary cows milk protein allergy.


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Nutrition

Use of zinc supplements ?- In patients with pre existing malnutrition.

Acrodermatitis enteropathica


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Prevention

Improved sanitation alone does not seem to reduceincidence worldwide

Vaccination is single most effective preventive strategy WHO in 2009 has put up a recommendation to

introduce rotavirus vaccine in all national immunizationprogram but take up rate is low (only 28 countries) dueto various factors

The Philippines is the first SEA country that hasintroduced rotavirus vaccination into their nationalimmunization program


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Rotavirus vaccines

First licensed in August 1998 for infants less than 6 mths(ROTASHIELD) but withdrawn October 1999 due to excess

number of recipient who developed intussuception during

post-licensure surveillance

Rotateq and Rotarix were reintroduced in 2006 followinglandmark clinical trials which demonstrated its safety and

efficacy


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BASIC FEATURES OF ROTATEQ ROTARIX VACCINES

RotaTeq Rotarix

Pharmaceutical company Merck & Co. GlaxoSmithKline

Origin Human/bovine reassortant Human attenuated

Valency Pentavalent Monovalent

Serotypes G1, G2, G3, G4, P[8] G1P[8]

Number of doses Three Two

Numberof children enrolled 70 301 63 225

Study locations Five each of European and 11 Latin American

Latin American countries countries andTaiwan and the United States Finland

Efficacy against

Any AGE 74% 87%

Severe AGE 98% 96%

P t f t i t t ith iti lt f NREVSS l b t i b k f d


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Percentage of rotavirus tests with positive results from NREVSS laboratories, by week of year and

region . JE Tate et al Trends in National Rotavirus Activity before and after introduction of Rotavirus

Vaccine into the National Immunization Program in the US, 2000-2012. The Pediatric Infectious

Disease Journal May 2013


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Lee et al. Rotavirus genotypes in Malaysia and Universal

rotavirus vaccination. Human Vaccines & Immunotherapeutics 8:10, 1-6;

October 2012

The projected annual reduction in RVGE-related deaths was 27 to 32 deaths (from

34 deaths) for Rotateq and 28 to 32 deaths annually for Rotarix


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So it is effective but why the take up rate is low ??

Main benefit of reducing mortality in low income countries

Many suggest the lack of cost savings for morbidity primarilybecause the price of vaccines is high (middle income

countries)

Cost is also an issue in wealthy developed countries to justify

the necessity for routine vaccination


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Quite recently.


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Thank You

Rotavirus Gastroenteritis FMS

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