[Nosocomial rotavirus infections in a general pediatric ward: epidemiology, molecular typing and risk factors]

Nosocomial rotavirus infections: a meta-analysis

BACKGROUND AND OBJECTIVES

Nosocomial rotavirus (nRV) infections represent an important part of rotavirus (RV)-associated morbidity. The incidence of nRV influences the estimated total RV disease burden, an important determinant of cost-effectiveness of RV vaccination programs. Our aim is to summarize the existing evidence and produce reliable estimates of nRV incidence, in pediatric settings in Europe and North America.

METHODS

We searched electronic databases for studies on nRV incidence among pediatric inpatients. To ascertain complete case reporting, only studies describing active nRV surveillance in their methodology were included. Random effects meta-analysis was performed. Meta-regression was used to obtain results adjusted for important study characteristics.

RESULTS

Twenty surveillance studies met the quality criteria for inclusion. The pooled unadjusted nRV incidence was 2.9 per 100 hospitalizations (95% confidence interval [CI]: 1.6-4.4). Incidence was significantly influenced by studies' seasonality-months (RV epidemic season only or year-round) and the age range of included patients. Highest nRV incidence was found for children <2 years of age, hospitalized during the epidemic months (8.1/100 hospitalizations; 95% CI: 6.4-9.9). The adjusted year-round nRV incidence estimate without age restriction was 0.4/100 hospitalizations (95% CI: 0.1-2.1) and 0.7 (95% CI: 0.0-1.8) for children <5 years of age.

CONCLUSIONS

This is the first meta-analysis to summarize results of surveillance studies on nRV incidence. nRV is an important problem among hospitalized infants during the winter months. The lower season and age-adjusted nRV incidence estimate seems more appropriate for application in population-based burden of disease analysis.

Burden of community-acquired and nosocomial rotavirus gastroenteritis in the pediatric population of Western Europe: a scoping review

BACKGROUND

Rotavirus affects 95% of children worldwide by age 5 years and is the leading cause of severe dehydrating diarrhea. The objective of this review was to estimate the burden of rotavirus gastroenteritis (RVGE) in the Western European pediatric population.

METHODS

A comprehensive literature search (1999-2010) was conducted in PubMed and other sources (CDC; WHO, others). Data on the epidemiology and burden of RVGE among children < 5 years-old in Western Europe --including hospital-acquired disease--were extracted.

RESULTS

76 studies from 16 countries were identified. The mean percentage of acute gastroenteritis (AGE) cases caused by rotavirus ranged from 25.3%-63.5% in children < 5 years of age, peaking during winter. Incidence rates of RVGE ranged from 1.33-4.96 cases/100 person- years. Hospitalization rates for RVGE ranged from 7% to 81% among infected children, depending on the country. Nosocomial RVGE accounted for 47%-69% of all hospital-acquired AGE and prolonged hospital stays by 4-12 days. Each year, RVGE incurred $0.54- $53.6 million in direct medical costs and $1.7-$22.4 million in indirect costs in the 16 countries studied. Full serotyping data was available for 8 countries. G1P[8], G2P[4], G9P[8], and G3P[8] were the most prevalent serotypes (cumulative frequency: 57.2%- 98.7%). Serotype distribution in nosocomial RVGE was similar.

CONCLUSIONS

This review confirms that RVGE is a common disease associated with significant morbidity and costs across Western Europe. A vaccine protecting against multiple serotypes may decrease the epidemiological and cost burden of RVGE in Western Europe.

Nosocomial Rotavirus Gastroenteritis in pediatric patients: a multi-center prospective cohort study

Background

Few data are available on the incidence of nosocomial Rotavirus infections (NRVI) in pediatric hospitals and on their economic impact. The goals of this study were: to evaluate the incidence of NRVI in various Italian pediatric wards during the course of two peak RV seasons; to investigate possible risk factors for NRVI; to estimate the costs caused by NRVI.

Methods

prospective cohort study. Population: all the children under 30 months of age who were admitted without any symptom or diagnosis of gastroenteritis in the pediatric hospitals of Florence, Naples, Brescia and Ancona, Italy, during the winter-spring periods 2006-2007 and 2007-2008. Serial RV rapid tests and clinical monitoring were carried out on the cohort. Telephone interviews were performed from 3 to 5 days after discharge.

Results

520 out of 608 children completed the study (85.6%). The overall incidence of NRVI was 5.3% (CI95% 3.6-7.5), (7.9 per 1,000 days of hospital stay, CI 95% 5.3-11.3). The average duration of hospital stay was significantly longer for children who had NRVI (8.1 days, SD 5.4) than for non-infected children (6.4 days, SD 5.8, difference 1.7 days, p = 0.004). The risk of contracting NRVI increased significantly if the child stayed in hospital more than 5 days, RR = 2.8 (CI95% 1.3-6), p = 0.006. In Italy the costs caused by NRVI can be estimated at 8,019,155.44 Euro per year. 2.7% of the children hospitalized with no gastroenteritis symptoms tested positive for RV.

Conclusions

Our study showed a relevant incidence of NRVI, which can increase the length of the children's stay in hospital. Limiting the number of nosocomial RV infections is important to improve patients' safety as well as to avoid additional health costs.

Burden of rotavirus gastroenteritis and potential benefits of a pentavalent rotavirus vaccination in Belgium

OBJECTIVE AND METHODS

A decision analytic model was built to assess the paediatric rotavirus gastroenteritis (RVGE) burden and potential benefits associated with the introduction of RotaTeq (pentavalent rotavirus vaccine) in Belgium.

RESULTS

In the absence of a rotavirus (RV) immunisation programme, paediatric RVGE was estimated to account for about 5,860 hospitalisations, 1,720 cases of nosocomial infections, 9,410 cases treated by general practitioners/paediatricians (GP/P) and 10,790 cases not seeking medical care for a birth cohort followed up to 5 years of age. Paediatric RVGE was estimated to cost about euro9.0 million from the Belgian healthcare provider perspective and euro15.3 million to society. Given a 90% RV vaccination coverage rate, the pentavalent RV vaccine would have a high impact on RV burden by preventing more than 4,850 hospitalisations, 995 cases of nosocomial infections, 7,145 cases treated by GP/P and 8,190 cases not seeking medical care, and reduce RVGE costs by euro7.1 million from the Belgian healthcare provider perspective and euro12.0 million to society.

Burden of paediatric rotavirus gastroenteritis and potential benefits of a universal rotavirus vaccination programme with RotaTeq in France

This study aimed at estimating the paediatric RotaVirus GastroEnteritis (RVGE) burden in children aged up to 5 years, and at evaluating health and economic benefits of a universal infant vaccination with a pentavalent rotavirus vaccine, in France. A decision analytic model was constructed considering a cohort of French children from birth to 5 years old. In the absence of a universal rotavirus immunisation programme, the model predicts that of every new French birth cohort, 336,738 children would present a RVGE case, which would result in 33,386 hospitalisations, 14 deaths and more than 279,000 work days lost for the parents. The management of these RVGE cases would cost 63 million euro to the National Healthcare Payer and would reach up to 117 million euro when all indirect costs were included. The introduction of a universal rotavirus vaccination would avoid 249,400 RVGE cases and consequently about 25,700 hospitalisations, 6000 nosocomial infections, 81,200 emergency visits, 39,900 general practitioner or paediatrician consultations, 11 deaths and 206,700 parental work days lost. RVGE total costs would be reduced by 47 million euro for the National Healthcare Payer and by 88 million euro from the Societal perspective. Therefore, a routine universal rotavirus vaccination programme represents an opportunity to significantly reduce the high paediatric RVGE burden in France.

Rotavirus vaccines: considerations for successful implementation in Europe

A group of European experts in infectious diseases and vaccinology has met on several occasions to assess the rationale for universal vaccination against rotavirus infection of infants in Europe. On the basis of the available data, we concluded that vaccination was the best approach to prevent severe rotavirus gastroenteritis, and that European countries should consider implementing rotavirus vaccination in their routine immunisation programmes. The main barrier to the implementation of rotavirus vaccination in Europe is a general lack of awareness of stakeholders, policymakers, health-care professionals, and parents about rotavirus disease and the advantages of vaccination. Further studies on the cost of the disease and the benefit of vaccination, together with raising awareness are necessary steps to ensure successful implementation of rotavirus vaccination in Europe.

[Nosocomial rotavirus infections in a pediatric unit: surveillance during four successive winters]

The incidence of rotavirus and RSV outbreaks during winter seasons leads to overcrowding of pediatric units in the Paris area, and increases the risk of viral nosocomial infections in hospitalized young infants.

OBJECTIVE

The aim of this study was to measure the incidence of rotavirus nosocomial infections in children less than 2 years of age during 4 consecutive winters.

METHODS

All infants admitted in the pediatric unit during the winter were prospectively screened for rotavirus with a stools exam. All children with negative stools examination on admission but developing diarrhea after 2 days of hospitalization underwent a new screening test for rotavirus in stools.

RESULTS

During the 4 consecutive winters, the global incidence of nosocomial rotavirus infection was 13.9% (12.7 to 15.9%). Asymptomatic carriage of rotavirus was detected in 3% of admitted infants. The risk of nosocomial rotavirus infection increases with young age and the length of hospital stay.

CONCLUSION

The incidence of nosocomial rotavirus infections was high in this unit. It is related to overcrowding due to coincidence of diarrhea and bronchiolitis outbreaks in the Paris area and to the young age of hospitalized patients.

The paediatric burden of rotavirus disease in Europe

Rotaviruses are a major cause of hospitalizations for acute gastroenteritis in developed countries. This review shows the burden of rotavirus disease in < 5-year-old children in Europe. An estimated 72,000-77,000 hospitalizations for community-acquired rotavirus disease occur annually in the 23 million under-fives living in the European Union (EU-25), with a median cost of Euro 1417 per case. Annual hospitalization incidence rates range from 0.3 to 11.9/1000 children < 5 years old (median 3/1000). The median proportion of hospital-acquired rotavirus disease among all cases of hospitalization for rotavirus disease is estimated to be 21%. Countries of the EU-25 require information on the burden of rotavirus disease to support introduction of rotavirus vaccines. Data on cases treated at home, medical visits, and emergency wards as well as rotavirus-associated deaths are limited. To fully evaluate the impact and effectiveness of rotavirus vaccination programmes in Europe, additional epidemiological studies will be critical and desirable.

Nosocomial rotavirus infection in European countries: a review of the epidemiology, severity and economic burden of hospital-acquired rotavirus disease

The data currently available on the epidemiology, severity and economic burden of nosocomial rotavirus (RV) infections in children younger than 5 years of age in the major European countries are reviewed. In most studies, RV was found to be the major etiologic agent of pediatric nosocomial diarrhea (31-87%), although the number of diarrhea cases associated with other virus infections (eg, noroviruses, astroviruses, adenoviruses) is increasing quickly and almost equals that caused by RVs. Nosocomial RV (NRV) infections are mainly associated with infants 0-5 months of age, whereas community-acquired RV disease is more prevalent in children 6-23 months of age. NRV infections are seasonal in most countries, occurring in winter; this coincides with the winter seasonal peak of other childhood virus infections (eg, respiratory syncytial virus and influenza viruses), thus placing a heavy burden on health infrastructures. A significant proportion (20-40%) of infections are asymptomatic, which contributes to the spread of the virus and might reduce the efficiency of prevention measures given as they are implemented too late. The absence of effective surveillance and of reporting of NRV infections in any of the 6 countries studied (France, Germany, Italy, Poland, Spain and the United Kingdom) results in severe underreporting of NRV cases in hospital databases and therefore in limited awareness of the importance of NRV disease at country level. The burden reported in the medical literature is potentially significant and includes temporary reduction in the quality of children's lives, increased costs associated with the additional consumption of medical resources (increased length of hospital stay) and constraints on parents'/hospital staff's professional lives. The limited robustness and comparability of studies, together with an evolving baseline caused by national changes in health care systems, do not presently allow a complete and accurate overview of NRV disease at country level to be obtained. RV is highly contagious, and the efficiency of existing prevention measures (such as handwashing, isolation and cohorting) is variable, but low at the global level because of the existence of numerous barriers to implementation (eg, lack of staff, high staff turnover, inadequate hospital infrastructure). Prevention of RV infection by mass vaccination could have a positive impact on the incidence of NRV by reducing the number of children hospitalized for gastroenteritis, therefore reducing the number of hospital cross-infections and associated costs.

Infections nosocomiales virales dans un service de pédiatrie : l'exemple des gastroentérites à rotavirus et des bronchiolites à VRS

Nosocomial infections are a preoccupation in a pediatric hospital mainly during the winter with bronchiolitis and gastroenteritis epidemics. We have examined the risk factors of nosocomial infections.

MATERIAL AND METHODS

A prospective study was conducted between November, 1999 and March, 2000 in the infants units of the Le Havre hospital. We systematically listed the admissions and contacted the family after their discharge by phone. A geographic information system was implemented to display the epidemiological data; this software is able to illustrate the sectors at risk.

RESULTS

During the study, 687 infants were hospitalized of whom 458 for bronchiolitis and community-acquired gastroenteritis. Mean age was 5.4 months old. No nosocomial bronchiolitis occurred. Prevalence of nosocomial gastroenteritis was 10% (68 cases including nine after discharge). Infants with nosocomial infection were younger than those with community-acquired infection (6.6 months vs. 11.2 months, P < 0.01). The mean length of stay was longer in nosocomial infection (7.7 vs. 4.1 days, P < 0.05). Among the infants with bronchiolitis, 16% have developed nosocomial intestinal infections (RR = 2.65, IC: 1.59-4.4; P < 0.01). The geographic analysis pointed the area with nosocomial risk (bedroom without water, nearness of nurse office and games room).

CONCLUSION

Geographic information system is a part of the quality control system and may have some interaction effect on final decision making. Incidence of nosocomial infections showed the need for a prevention strategy in a pediatric hospital.

Infection nosocomiale à rotavirus en pédiatrie générale. Enquête d’observation multicentrique

OBJECTIVE

Rotavirus nosocomial infection (RNI) is frequent in pediatric units. This study was designed to determine the incidence and the main risk factors of RNI in children aged 3 months-3 years and admitted for at least 48 hours days during the epidemic period.

PATIENTS AND METHODS

A stool sample was obtained within the 24 hours of admission. An additional sample was collected from rotavirus-negative children either the day of discharge, or when they developed abnormal clinical signs. Parents were contacted by phone after discharge. Children initially rotavirus-negative and positive 2 days or more after admission were considered as certain nosocomial cases. In the absence of the second sample, possible nosocomial cases were considered if new symptoms (i.e.; fever and or digestive symptoms) occurred 2 days or more after the first negative sample.

RESULTS

One hundred and seventeen children were included. The incidence was 11.1% for certain NRI, 16.8% for possible hospital-acquired cases and 19.4% for the whole cases. Possible risk factors were the low number of nurses during the weekend, the great number of medicine students in the unit, and no use of individual material.

CONCLUSION

NRI have a high incidence, whose reality can only be approximated by taking into account the possible NRI occurring at home after hospital-discharge.

Clinical utility of nested multiplex RT-PCR for group F adenovirus, rotavirus and norwalk-like viruses in acute viral gastroenteritis in children and adults

BACKGROUND

The diagnosis of viral gastroenteritis can be carried out by non-molecular techniques such as electron microscopy (EM), enzyme-immunoassay and latex agglutination tests and various molecular techniques. Normally molecular detection requires the use of three separate protocols to detect the three main causes of viral gastroenteritis, adenoviruses, rotaviruses and norwalk-like viruses (NLV) which have different types of nucleic acid. The development of a sensitive and specific assay which could detect these targets would have major advantages for the clinical virology laboratory.

OBJECTIVES

The aims of the present study were to develop a sensitive and specific multiplex molecular assay and to apply it to the detection of viral agents in clinical cases of acute gastroenteritis.

STUDY DESIGN

The multiplex assay was designed using Access RT-PCR (Promega). Primers were researched and selected for their specificity and broad range detection of the viral agents across the various genotypes of group A rotaviruses, NLV and group F adenoviruses.

RESULTS

From September 2000 to August 2001 we tested 1945 clinical specimens. Rotavirus infections were detected in 190 with an age range from 12 days to 8 years old. Group F adenovirus was detected in 96 patients ranging from 15 days to 10 years old. A further single case of group F adenovirus was detected in an adult of 75 years old. NLVs were detected in 132 patients. There were 55 infections in children less than 7 years old. In 10 different outbreaks involving 130 adult patients there were 57 NLV positives. Sporadic NLV infection was detected in 11 of 600 adult patients. There were 4 patients with dual infections.

CONCLUSIONS

The assay detailed here has proved an invaluable tool for the investigation of acute gastroenteritis in specimens from patients of all ages. We found it convenient to use a single mastermix with a single protocol to test all specimens from patients of all ages. NLV in children is often overlooked and/or under reported, particularly where less sensitive assays such as EM are being employed for diagnosis.

Epidemiology of acute viral gastroenteritis in children hospitalized in Rouen, France

This study assessed the epidemiologic characteristics of acute viral gastroenteritis in hospitalized children. A stool sample obtained from each child was analyzed for the presence of astrovirus, calicivirus, rotavirus, adenovirus, enterovirus, and digestive bacteria. Of the 438 stool samples obtained, 138 tested positive for > or =1 pathogen during the winters of 1997-1998 and 1998-1999 (P<.001). Virologic tests revealed rotavirus in 17.3% of samples, calicivirus in 7.3%, astrovirus in 6.8%, adenovirus in 0.7%, and > or =1 virus in 5.4%. Median age was higher for patients with rotavirus gastroenteritis than it was for those with astrovirus or calicivirus gastroenteritis (P=.014). Mean duration of hospitalization was statistically significantly lower for children with rotavirus gastroenteritis (P=.022), despite the more-frequent dehydration observed among children with rotavirus versus those with astrovirus or calicivirus gastroenteritis (P=.007). In contrast, enteral rehydration was more rapidly achieved in patients with gastroenteritis due to rotavirus.