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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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We do have Rotavirus deaths
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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We do have Rotavirus deaths
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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