Study of the incidence and clinical profile of rotaviral gastroenteritis.

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

2. Original Article
Study of clinical profile of rotaviral gastroenteritis
among patients admitted in a tertiary care hospital
Kochurani Abraham a
, Sanjay Bafna b,
*, Leena Hiremath c
, Shailesh Muley d
a
Senior Registrar, Dept of Paediatrics, Jehangir Hospital (Apollo Group Hospital), Pune, India
b
Senior Consultant Paediatrician, HOD, Dept of Paediatrics, Jehangir Hospital (Apollo Group Hospital), Pune, India
c
Senior Consultant Paediatrician, Dept of Paediatrics, Jehangir Hospital (Apollo Group Hospital), Pune, India
d
DNB 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 1 month 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 ) 2 e5
http://dx.doi.org/10.1016/j.apme.2014.02.003
0976-0016/Copyright ª 2014, Indraprastha Medical Corporation Ltd. All rights reserved.

3. 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 samples were 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 patients with 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-
sented with fever, loose motions 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 cause most 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.
a p o l l o m e d i c i n e 1 1 ( 2 0 1 4 ) 2 e5 3

4. 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 that nearly 18% of them were due to rotavirus and more
recent reviews of 10 studies from 1999 to 2004 showed an inci-
dence of 23.4% of rotaviral diarrhea in children admitted with
gastroenteritis.13
A multicentre hospitalbased studyofrotaviral
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.
a p o l l o m e d i c i n e 1 1 ( 2 0 1 4 ) 2 e54

5. 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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