|Year : 2020 | Volume
| Issue : 1 | Page : 37-41
Prevalence of Rotavirus diarrhea among under-five hospitalized children in government tertiary hospital, Tirupati
Manohar Badur1, Ravi Kumar Panabaka1, Madhavi Latha Naramalli2, Shankar Reddy Dudala3, Shabbir Ali Shaik1, Gagandeep Kang4, Naveen Kumar Cheri1
1 Department of Pediatrics, S.V. Medical College, Tirupati, AP, Vellore, Tamil Nadu, India
2 Department of Bio-chemistry, S.V. Medical College, Tirupati, AP, Vellore, Tamil Nadu, India
3 Department of Community Medicine, S.V. Medical College, Tirupati, AP, Vellore, Tamil Nadu, India
4 Department of Gastrointestinal Sciences, Christian Medical College, Vellore, Tamil Nadu, India
|Date of Submission||14-Nov-2014|
|Date of Decision||23-Jan-2015|
|Date of Acceptance||18-Jan-2020|
|Date of Web Publication||14-May-2020|
Dr. Manohar Badur
Professor of Pediatrics and Co.investigator ICMR - National Rotavirus Surveillance Network (NRSN), Department of Pediatrics, S.V. Medical College and S.V.R.R. Government General Hospital, Tirupati - 517507, Andhra Pradesh
Source of Support: None, Conflict of Interest: None
Context: Rotavirus is the most common cause of severe diarrhea requiring hospitalization among infants and young children worldwide. The prevalence of Rotavirus diarrhea in India has been found to vary from 5% to 71% in hospitalized children less than 5 years of age with acute gastroenteritis. The seasonal variation of Rotavirus diarrhea in India varies in different geographical regions with high incidence in winter months, at low relative humidity in north India.
Aim: To estimate the prevalence of Rotavirus diarrhea among the hospitalized children of age less than 5 years. To know the genotypic distribution of Rotavirus causing diarrhea.
Settings and Design: Study design: Hospital-based cross-sectional study. Study setting: Pediatrics Department of Sri Venkateswara Ram Naraian Ruya Government General Hospital, Tirupati. Study period: 20th September 2012 to 19th September 2013.
Methods and Materials: Study units: Children less than 5 years of age presenting with diarrhea. Stool specimens from all hospitalized children of age less than 5 years who had presented with acute watery diarrhea were collected and tested for Rotavirus by enzyme-linked immunosorbent assay (ELISA). Positive samples were tested for G and P typing by reverse transcription polymerase chain reaction technique.
Statistical Analysis Used: Percentage and Chi-square analysis.
Results: Among the study sample, 68.7% of children were in the age group between 1 and 12 months and 25.6% of children showed positive result for Rotavirus by ELISA. Of the Rotavirus positives, 50% were G1P8 viruses.
Conclusion: Rotavirus is an important cause of diarrhea in hospitalized children.
Keywords: Diarrhea, ELISA, genotyping, Rotavirus, Tirupati
|How to cite this article:|
Badur M, Panabaka RK, Naramalli ML, Dudala SR, Shaik SA, Kang G, Cheri NK. Prevalence of Rotavirus diarrhea among under-five hospitalized children in government tertiary hospital, Tirupati. J NTR Univ Health Sci 2020;9:37-41
|How to cite this URL:|
Badur M, Panabaka RK, Naramalli ML, Dudala SR, Shaik SA, Kang G, Cheri NK. Prevalence of Rotavirus diarrhea among under-five hospitalized children in government tertiary hospital, Tirupati. J NTR Univ Health Sci [serial online] 2020 [cited 2020 Sep 26];9:37-41. Available from: http://www.jdrntruhs.org/text.asp?2020/9/1/37/284313
| Introduction|| |
Rotavirus is the most common cause of severe diarrhea requiring hospitalization among infants and young children worldwide. Very few studies on the prevalence of Rotavirus among children have been conducted in Andhra Pradesh. Rotavirus infections spread easily through multiple modes of transmission. Rotavirus infections also spread in settings where many children are together, such as day-care centers and nurseries. Marked seasonality is seen in temperate or cooler climates, where outbreaks usually occur in the winter and early spring, between about November and April. Rotaviruses are classified based on the most abundant protein VP6 into Groups A-G, with Groups A-C infecting humans. Among them, Group A Rotavirus is the most important human pathogen. Diarrhea caused by Rotaviruses may be due to impaired sodium and glucose absorption as damaged cells on villi are replaced by non-absorbing immature crypt cells.
Exposure to infection occurs in early life. By the age of 3 years, 90% of the children have serum antibodies to one or more types of Rotavirus indicating high levels of exposure. Several studies on Rotavirus epidemiology have been carried out in different parts of India. The previous studies in the Indian Rotavirus Strain Surveillance Network have confirmed that Rotavirus accounts for 39% of acute diarrheal hospitalizations. This study aimed to identify the proportion of children with acute gastroenteritis infected with Rotavirus through systematic sampling over one-year period in a tertiary care Government hospital in Andhra Pradesh.
| Subjects and Methods|| |
The study was conducted at the Pediatric Department of Sri Venkateswara Ram Naraian Ruya Government General Hospital, which is a Government tertiary care center in Tirupati, from 20th September 2012 to 19th September 2013. This study included all hospitalized children of age less than 5 years who had presented with acute watery diarrhea. Informed consent was obtained from the respective parent/guardian after explaining the purpose of the study. A case of diarrhea was defined as increased stool frequency compared with the usual pattern occurring in a child less than 5 years old for whom parents sought care for treatment of diarrhea. Clinical details, including age, sex, duration of illness, number of stools, associated vomiting and fever, degree of dehydration, and concomitant illness were recorded on a standardized case reporting form. This study is part of an Indian council of medical research (ICMR) funded project for National Hospital-Based Rotavirus Surveillance Network. The Department of Pediatrics in Sri Venkateswara Medical College, Tirupati, is one of the study sites of the multi centric project and obtained Institutional Ethical Committee approval prior to study initiation [IEC / SVMC No.: 07/06/2012, Lr. No:04/2012].
Stool specimens from all hospitalized children of age less than 5 years who had presented with acute watery diarrhea were collected and stored in the refrigerator at 4°C and later transported to the base hospital in icebox. All the stool samples were sent to the testing laboratory at the Christian Medical College (CMC), Vellore at 4°C. Samples were tested for the presence of Rotavirus using a commercially available antigen detection enzyme-linked immunosorbent assay (ELISA) (Premier™ Rotaclone®, Meridian Biosciences) as per kit protocol. Samples showing an optical density value of ≥0.150 were reported as positive. An internal control was included in all runs, and the run was repeated if the internal control did not fall in the expected range.
Genotyping was performed on the antigen-positive samples. Ribonucleic acid (RNA) was extracted using the QIAamp Viral RNA Mini Kit. Complementary Deoxyribonucleic acid (DNA) was synthesized using random primers [Pd(N)6 hexamers; Pharmacia Biotech] and 400 units of Moloney murine leukemia virus reverse transcriptase (Invitrogen Life Technologies) and was used as template for VP7 and VP4 (G and P) typing in polymerase chain reactions using published oligonucleotide primers and protocols to detect VP7 genotypes G1, G2, G3, G4, G8, G9, G10, and G12 and VP4 genotypes P, P, P, P, P, and P.
Data was collected and entered into excel software which was later analyzed using SPSS version 16.0. Appropriate statistical tests like calculating percentage and Chi-square analysis were applied.
| Results|| |
For the one-year period, a total of 187 children were included in the study group. Among the study subjects, the majority of them were male children 107 (57.2%) and 80 (42.8%) were female children. Month--wise distribution of hospitalized cases presented with diarrhea across the year is shown in [Figure 1]. Stool samples of 48 (25.67%) children were positive for Rotavirus by ELISA. [Table 1] Among 187 cases, majority 110 (58.8%) were in the age group between 1 to 12 months. Similarly, out of 48 ELISA positive cases, 33 (17.7%) were found between the same age group. There were no Rotavirus infected cases among neonates and in the age group of 48–60 months. [Table 2] Applying Chi-square analysis, it was found that there is no statistically significant difference in ELISA reactivity between different age groups of cases. Of 48 ELISA positives, 24 (50%) belonged to G1P8 type. [Table 3] Out of the 48 ELISA positive cases, 27 belong to G1 type followed by G12 and G2. [Table 4] Most (32) of the Rotavirus belonged to P8 type. [Table 5].
|Figure 1: Figure-1 shows the month-wise distribution of hospitalized cases presented with diarrhea across the year. The number of cases appears to increase during summer even though there is an uneven distribution of cases in other seasons|
Click here to view
| Discussion|| |
In the present study, it was found that 25.66% of the children, aged less than 5 years, hospitalized with the complaint of diarrhea are due to Rotavirus. The Indian Rotavirus Strain Surveillance Network carried out a multi-centric study in seven different regions of India and reported that Rotavirus was detected in stools of 39% children aged less than 5 years., Studies in other parts of Asia have shown a much higher prevalence rate, perhaps due to the absence or lower rates of other causes of acute gastroenteritis. A few studies done in Indian outpatient facilities and in the community revealed that 30% of cases were less than 6 months of age.,
In Chandigarh, Rotavirus was detected in 16%–19% of instances of acute gastroenteritis in children less than 5 years of age,,, while in Aligarh it was detected in 19% of cases of acute diarrhea. In the eastern states of India and in Pune, Rotavirus was detected in 28%–30% of children less than 5 years of age with acute diarrhea., In Kolkata, the incidence of Rotavirus associated diarrhea varied from 5%–22%,, but in Manipur, the incidence was as high as 41%. However, it is important to note that these studies did not use similar methods and, therefore, direct comparison of results is difficult.
Regarding seasonality, some studies in India have found no association between Rotavirus infection and the time of year., Other studies have observed an increase in Rotavirus-associated diarrhea during the winter months, October to February, throughout the country.,, Rotavirus is markedly seasonal in northern India but was less seasonal in southern locations with a more tropical climate.,, In the present study, although cases increased from December to April, there was an uneven distribution throughout the year.
In the present study, 56.25% of the Rotavirus was of G1P genotype followed by G12P (14.5%) and G12 [P8] (12.5%). In a study from Kolkata, the predominant genotype was G1P (20%), followed by G2P (15%) and G4P (6%). A number of uncommon genotypes G1P (4%), G2P (2.5%), G2P (0.6%), G4P (2.5%), and G4P (1.25%) were also observed. A Rotavirus strain not common in India, G4P , was reported from children with acute diarrhea in another study at Kolkata.
In another study from Vellore in Tamil Nadu on 100 Rotavirus strains, the commonest G types seen were G1, G4, G2, G9, G3, and G8 in the order of frequency, and the P types were P, P, and P, and the most common G: P combinations were G1P, G1P, G2 P, and G4 P. A study done at Kerala also showed that G1P is the most common genotype followed by G9P. Tracking of strains is important to understand the epidemiology of disease and to monitor changes following vaccine introduction.
There were few limitations of the present study, namely, as this study is hospital based, the prevalence of Rotavirus may be different from a community-based study and also incidence of the disease cannot be calculated.
This study has made it clear that one-fourth of the diarrheal disorders among children of age less than 5 years are due to Rotavirus, which calls for stringent preventive measures in terms of compulsory vaccination against Rotavirus. Due importance should also be given to personal hygiene and handwashing practices of family members.
We are pleased to acknowledge Dr. M.S. Sridhar, MD, Principal, S.V. Medical College, Tirupati and Dr. J. Veeraswamy, MS, MCh, Superintendent, S.V.R.R. Government General Hospital for allowing us to conduct this study and their encouragement throughout. We are thankful to Dr. Rashmi Patnayak, Associate Professor of Pathology, SVIMS for necessary inputs.
We would like to acknowledge Smt. K. Punya Manohar for her constant support and encouragement throughout the study.
We appreciate the work done by Mr. S. Nandha Kumar, DECE, DMLT, Lab Technician, ICMR NRSN – Tirupati site, toward the completion of this clinical study.
We would like to thank Mr. M. Thirumani, Research Co-ordinator, Mr. A. Rajesh, Associate Research Officer, and other members of The Wellcome Trust Research Laboratory team, Division of Gastrointestinal Sciences, Christian Medical College, Vellore for their valuable assistance.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the guardians have given their consent for patient images and other clinical information to be reported in the journal. The guardians understand that patient names and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Indian Council for Medical research (ICMR).
Conflicts of interest
There are no conflicts of interest.
| References|| |
Rotavirus surveillance--worldwide, 2001-2008. Centers for Disease Control and Prevention (CDC). MMWR Morb Mortal Wkly Rep 2008; 57:1255-7.
Kang G, Kelkar SD, Chitambar SD, Ray P, Naik T. Epidemiological profile of rotaviral infection in India: Challenges for the 21st
century. J Infect Dis 2005;192(Suppl 1):120-6.
Mustafa NS, Elhag WI. Diagnosis of rotavirus gastroenteritis by a latex agglutination test in Khartoum State, Sudan. J Pharm Biomed Sci 2013;33:1594-8.
Kang G, Arora R, Chitambar SD, Deshpande J, Gupte MD, Kulkarni M, et al.
Multicenter, hospital-based surveillance of rotavirus disease and strains among Indian children aged <5 years. J Infect Dis 2009; 200:S147-53.
Bhatnagar S, Lodha R, Choudhary P, Sachdev HP, Shah N, Narayan S, et al.
IAP Guidelines 2006 on management of acute diarrhea. Indian Pediatr 2007;44:380-9.
Nelson EA, Bresee JS, Parashar UD, Widdowson MA, Glass RI. Rotavirus epidemiology: The Asian Rotavirus Surveillance Network. Vaccine 2008; 26:3192-6.
Kelkar SD, Purohit SG, Boralkar AN, Verma SP. Prevalence of rotavirus diarrhea among outpatients and hospitalized patients: A comparison. Southeast Asian J Trop Med Public Health 2001;32:494-9.
Banerjee I, Ramani S, Primrose B, Moses P, Iturriza- Gomara M, Gray JJ, et al.
Comparative study of the epidemiology of rotavirus in children from a community based birth cohort and a hospital in South India. J Clin Microbiol 2006;44:2468-74.
Broor S, Singh V, Venkateshwarlu, Gautam S, Mehta S, Mehta SK. Rotavirus diarrhoea in children in Chandigarh, India. J Diarrhoeal Dis Res1985;3:158-61.
Singh V, Broor S, Mehta S, Mehta SK. Molecular epidemiology of human rotavirus infections in Chandigarh (India). Indian J Med Res1990;91:9-14.
Sharma P, Sehgal R, Ganguly NK, Vaidyanathan U, Walia BN. Serogroups of rotavirus in north India. J Trop Pediatr1994;40:58-9.
Malik A, Rattan A, Malik MA, Shukla I. Rotavirus diarrhoea of infancy and childhood in a north Indian town-epidemiological aspects. J Trop Pediatr 1987;33:243-5.
Jain V, Das BK, Bhan MK, Glass RI, Gentsch JR, Indian strain surveillance collaborating laboratories. Great diversity of group A rotavirus strains and high prevalence of mixed rotavirus infections in India. J Clin Microbiol 2001;39:3524-9.
Kelkar SD, Purohit SG, Simha KV. Prevalence of rotavirus diarrhoea among hospitalized children in Pune, India. Indian J Med Res 1999;109:131-5.
Ghosh AR, Nair GB, Dutta P, Pal SC, Sen D. Acute diarrhoeal diseases in infants aged below six months in hospital in Calcutta, India: An aetiological study. Trans R Soc TropMed Hyg1991;85:796-8.
Saha MR, Bhattacharya SK, Mukherjee AK, Chakraborty BN, Pal SC. Prevalence of rotavirus infection among neonates in Calcutta. Indian J Med Res1984;80:620-2.
Jain V, Parashar UD, Glass RI, Bhan MK. Epidemiology of rotavirus in India. Indian JPediatr2001;68:855-62.
Mukherjee A, Chattopadhyay S, Bagchi P, Dutta D, Singh NB, Arora R, et al.
Surveillance and molecular characterization of rotavirus strains circulating in Manipur, north-eastern India: Increasing prevalence of emerging G12 strains. Infect Genet Evol 2010;10:311-20.
Bahl R, Ray P, Subodh S, Shambharkar P, Saxena M, Parashar U, et al
. Incidence of severe rotavirus diarrhea in New Delhi, India, and G andP types of the infecting rotavirus strains. J Infect Dis 2005;192:S114-9.
Saravanan P, Ananthan S, Ananthasubramanian M. Rotavirus infection among infants and young children in Chennai, South India. Indian J Med Microbiol 2004;22:212-21.
] [Full text]
Ray P, Sharma S, Agarwal RK, Longmei K, Gentsch Jr, Paul VK, et al.
First detection of G12 rotavirus in newborns with neonatal rotavirus infection at All India Institute of Medical Sciences, New Delhi, India. J Clin Microbiol 2007;45:3824-7.
Phukan AC, Patgiri DK, Mahanta J. Rotavirus associated acute diarrhoea in hospitalized children in Dibrugarh, North-east India. Indian J Pathol Microbiol 2003;46:274-8.
Das S, Sen A, Uma G, Varghese V, Chaudhuri S, Bhattacharya SK, et al.
Genomic diversity of group A rotavirus strains infecting humans in eastern India. J ClinMicrobiol 2002;40:146-9.
Khetawat D, Dutta P, Gupta S, Chakrabarti S. Emergence of rotavirus G4P strain among children suffering from watery diarrhoea in Calcutta, India. Intervirology 2001;44:306-10.
Brown DW, Mathan MM, Mathew M, Martin R, Beards GM, Mathan VI. Rotavirus epidemiology in Vellore, south India: Group, serogroup, serotype and electrophoretype. J Clin Microbiol 1988;26:2410-4.
Mathew MA, Paulose A, Chitralekha S, Nair MKC, Kang G, Kilgore P. Prevalence of rotavirus diarrhea among hospitalized under-five children. Indian Pediatr 2014;51:27-31.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]