An outbreak of diarrhea in a neonatal medium care unit caused by a novel strain of rotavirus: investigation using both epidemiologic and microbiological methods

Incidence, Clinical Characteristics, and Genotype Distribution of Rotavirus in a Neonatal Intensive Care Unit 5 Years After Introducing Rotavirus Vaccine

BACKGROUND

Rotavirus (RV) is a common cause of viral gastroenteritis in children worldwide. We aimed to investigate the incidence, symptoms, and genotype of RV infection in a neonatal intensive care unit (NICU) in South Korea 5 years after the introduction of RV vaccination to evaluate its effect on newborn infants.

METHODS

A total of 431 fecal specimens were collected from patients admitted to NICU between April 20, 2012 and September 10, 2013. Enzyme-linked immunoassays were used to detect RV antigen. Nested multiplex polymerase chain reaction was used for genotyping.

RESULTS

The overall incidence of RV infection was 43.9% and was significantly higher in preterm infants, infants born in the study hospital, low birth weight infants, and cesarean births (P < 0.05). Symptoms of diarrhea, poor feeding, abdominal distension, and apnea were significantly higher in infants with RV infection than those without infection. RV infection gradually increased depending on infant care at home, postpartum clinic, or hospital (26.0, 45.1, and 60.2%, respectively; P = 0.000). The dominant RV genotype in the NICU was G4P[6] at 95.4%.

CONCLUSION

Current RV vaccines did not affect the incidence of RV infection in newborn and preterm infants in the NICU. Most RV-positive patients in the NICU had symptoms, and the incidence of RV infection was relatively higher in hospitals and postpartum clinics with group life than home. The dominant RV genotype was G4P[6] across study groups.

Complete genomic analysis of uncommon G12P[11] rotavirus causing a nosocomial outbreak of acute diarrhea in the newborns in New Delhi, India

Rotaviruses (RVs) are the major causative agents of acute gastroenteritis in children, but in neonates, RV infections are generally nosocomial in origin and mostly asymptomatic. However, there have been infrequent reports of nosocomial outbreaks of clinical disease in this population. In this study, we describe uncommon RV genotype; G12P[11] associated with an outbreak of acute gastroenteritis in the neonatal ward and neonatal intensive care unit (NICU) in New Delhi, North India. Full-genome analyses of the pathogenic G12P[11] strain was carried out to map the genotype constellation and further to explore the variations in the antigenic epitopes on the immunodominant VP7 and VP4 proteins, the amino acid sequences were compared with neonatal strains; ROTAVAC® (G9P[11]) and asymptomatic G12P[11] and also other G/P-type matched strains. The study revealed G12-P[11]-I1-R1-C1-M1-A1-N1-T1-E1-H1 human Wa-like genotype constellation and highlights evidence of gene reassortment. No significant differences were observed in the sequences of structural (except VP3) and nonstructural encoding genes of G12P[11] strains recovered from symptomatic and asymptomatic neonates. Presence of additional N-linked glycosylation site was noted in the G12 strains, as a consequence of a change from Asp→Asn at amino acid position 238. Interestingly, only two and four amino acids substitution within the 7-1a and 8-1 antigenic epitope were observed, respectively, compared with asymptomatic G12P[11] strain. The study emphasizes the importance of close monitoring of RV outbreaks in neonates for early alarming of novel strain.

Health Care–Associated Rotavirus Illness in Pediatric Inpatients in Germany, Austria, and Switzerland

A longitudinal study of health care-associated transmission of rotaviruses (RVs) in pediatric inpatients 0-48 months old in Austria, Germany, and Switzerland showed that almost one third of all cases occurred in patients 2 months old or younger. The effectiveness of vaccination against RV from 2 months of age onward remains to be evaluated.

Use of ward closure to control outbreaks among hospitalized patients in acute care settings: a systematic review

BACKGROUND

Though often used to control outbreaks, the efficacy of ward closure is unclear. This systematic review sought to identify studies defining and describing ward closure in outbreak control and to determine impact of ward closure as an intervention on outbreak containment.

METHODS

We searched these databases with no language restrictions: MEDLINE, 1946 to 7 July 2014; EMBASE, 1974 to 7 July 2014; CINAHL, 1937 to 8 July 2014; and Cochrane Database of Systematic Reviews, 2005 to May 2014. We also searched the following: IndMED; LILACS; reference lists from retrieved articles; conference proceedings; and websites of the CDCP, the ICID, and the WHO. We included studies of patients hospitalized in acute care facilities; used ward closure as a control measure; used other control measures; and discussed control of the outbreak(s) under investigation. A component approach was used to assess study quality.

RESULTS

We included 97 English and non-English observational studies. None included a controlled comparison between ward closure and other interventions. We found that ward closure was often used as part of a bundle of interventions but could not determine its direct impact separate from all the other interventions whether used in parallel or in sequence with other interventions. We also found no universal definition of ward closure which was widely accepted.

CONCLUSIONS

With no published controlled studies identified, ward closure for control of outbreaks remains an intervention that is not evidence based and healthcare personnel will need to continue to balance the competing risks associated with its use, taking into consideration the nature of the outbreak, the type of pathogen and its virulence, mode of transmission, and the setting in which it occurs. Our review has identified a major research gap in this area.

Rotavirus Gastroenteritis in a Neonatal Unit of a Greek Tertiary Hospital: Clinical Characteristics and Genotypes

INTRODUCTION

Rotavirus (RV) infection in neonatal age can be mild or even asymptomatic. Several studies have reported that RV is responsible for 31%-87% of pediatric nosocomial diarrhea and causes gastroenteritis outbreaks in pediatric and neonatal units.

OBJECTIVES

Study clinical characteristics, genotypes and risk factors of RV infection in neonatal age.

METHODS

A prospective study was conducted from April 2009 till April 2013 in the neonatal special care unit of the largest tertiary pediatric hospital of Greece. Fecal samples and epidemiological data were collected from each neonate with gastrointestinal symptoms. RV antigen was detected with a rapid immunochromatography test. RV positive samples were further genotyped with RT PCR and sequencing using specific VP7 and VP4 primers.

RESULTS

Positive for RV were 126/415 samples (30.4%). Mean age of onset was 18 days. Seventy four cases (58%) were hospital acquired. Seasonality of RV infection did not differ significantly throughout the year with the exception of 4 outbreaks. Genotypes found during the study period were G4P[8] (58.7%), G1P[8] (14.7%), G12P[8] (9.3%), G3P[8] (9.3%), G12P[6] (5.3%), G9P[8] (1.3%) and G2P[4] (1.3%). RV cases presented with: diarrhea (81%), vomiting (26.2%), fever (34.9%), dehydration (28.6%), feeding intolerance (39.7%), weight loss (54%), whilst 19% of cases were asymptomatic. Comparing community with hospital acquired cases differences in clinical manifestations were found.

CONCLUSIONS

Significant incidence of nosocomially transmitted RV infection in neonatal age including asymptomatic illness exists. Genotypes causing nosocomial outbreaks are not different from community strains. Circulating vaccines can be effective in prevention of nosocomial RV infection through herd immunity.

Pseudo-outbreak of rotavirus infection in a neonatal intensive care unit

BACKGROUND

A rotavirus outbreak in a neonatal intensive care unit (NICU) may have catastrophic consequences for young infants receiving critical care. From May 13, 2011 to July 11, 2011, a significant increase in stool samples testing positive for rotavirus antigens in the NICU of a university affiliated hospital was observed. Due to lack of clinical presentations suggestive of rotavirus infection in the patients and the rarity of rotavirus infection in the NICU in the past, a pseudo-outbreak was suspected.

METHODS

Infection control measures were reinforced initially. To investigate the outbreak, a prospective laboratory-based active surveillance of all infants in the NICU was conducted right after the cluster was identified. Repeated testing using a modified enzyme immunoassay (EIA) kit, rotavirus RNA polyacrylamide gel electrophoresis (PAGE), reverse transcription polymerase chain reaction (RT-PCR), and retrospective chart review methods were used to confirm the pseudo-outbreak.

RESULTS

Seven infants in the NICU, with or without gastrointestinal symptoms, tested positive for the rotavirus antigen using the old version of an EIA kit, which indicated a possible outbreak. Active surveillance with repeated tests for recollected stool samples using a modified EIA kit showed negative results in all 24 infants in the NICU. Seven stored stool samples from four infants, which previously tested positive for the rotavirus antigen, tested negative for rotavirus using the modified EIA kit, PAGE, and RT-PCR. Chart reviews showed no clinical difference between index cases and controls. False positivity might arise from unsatisfactory specificity of the old EIA kit. After the introduction of the modified EIA kit, no rotavirus was detected in the NICU for at least 7 months.

CONCLUSION

This cluster of patients who tested positive for the rotavirus antigen in stools was confirmed to be a pseudo-outbreak. Interpretation of the old EIA for rotavirus in an NICU setting should be done with caution until the mechanism of the false-positive reaction is elucidated.

Do current cost-effectiveness analyses reflect the full value of childhood vaccination in Europe? A rotavirus case study

Economic evaluation of vaccination programs can be challenging and does not always fully capture the benefits provided. Reasons for this include the difficulties incurred in accurately capturing the health and economic impact of infectious diseases and how different diseases may interact with each other. Rotavirus infection, for example, peaks at a similar time than other infectious diseases, such as RSV and influenza, which can cause hospital overcrowding and disruption, and may pose a risk to more vulnerable children due to limited availability of isolation facilities. Another challenge, specific to evaluating childhood vaccination, is that QoL cannot be accurately measured in children due to a lack of validated instruments. Childhood diseases also incur a care giver burden, due to the need for parents to take time off work, and this is important to consider. Finally, for diseases such as RVGE, cost-effectiveness analyses in which longer time horizons are considered may not reflect the short-term benefits of vaccination. Further quantification of the economic impact of childhood diseases is thus required to fully highlight the true benefits of childhood vaccination that may be realized. Herein we explore the limitations of existing economic evaluations for childhood vaccination, and how economic analyses could be better adapted in future.

[Comparison of clinical characteristics of patients with rotavirus gastroenteritis relative to the infecting rotavirus g-p genotype.]

BACKGROUND

Group A rotavirus is a major cause of severe diarrhea in children throughout the world. For the proper management of rotavirus infections, it will be helpful to know their clinical characteristics according to the G and P genotypes of the infecting virus.

METHODS

The diarrheal stool specimens from patients hospitalized in Chosun University Hospital during 2002-2003 were tested for rotavirus by Dipstick 'Eiken' Rota kit. Rotavirus antigen-positive stool specimens were analyzed for group A rotavirus by RT-PCR, and the group A-positive PCR products were genotyped for P and G types by PCR.

RESULTS

Among the 119 specimens analyzed for genotypes, the predominant strain was genotype G4P[6] (51.3%), followed by G2P[4] (19.3%), G1P[8] (7.6%), G3P[8] (5.0%), and G9P[8] (4.2%). To examine the characteristics of each rotavirus genotype, a clinico-epidemiological study was performed for 100 patients whose medical records were available. The frequencies of diarrhea, vomiting, dehydration, and fever; the rates of nosocomial infection and transfer from other hospitals; and the mean severity scores were significantly different among the patients infected with different types of rotavirus. Especially, patients with G4P[6] type were more likely than those infected with other genotypes to show the following distinct features: Most patients showed milder symptoms and were neonates transferred from other obstetric hospitals and 68.4% of the cases were nosocomial infection. G4P[6] strains were isolated almost all along the year. The mean severity scores of patients infected by G4P[6], G2P[4], G1P[8], G3P[8], and G9P[8] strains were 6.8, 9.5, 8.0, 9.0, and 10.8, respectively.

CONCLUSIONS

Many features of rotavirus infections including the epidemic period, rate of nosocomial infection, age and severity of symptoms were different according to the genotypes of the infecting virus.

Epidemiology of Klebsiella oxytoca-associated diarrhea detected by Simmons citrate agar supplemented with inositol, tryptophan, and bile salts

We studied the clinical and epidemiological characteristics of Klebsiella oxytoca-associated diarrhea in hospitalized patients in Hong Kong. Between 1 November 2009 and 30 April 2011, all inositol-fermenting colonies found on Simmons citrate agar supplemented with inositol, tryptophan, and bile salts (SCITB agar) used for the culturing of diarrheal stool samples were screened by a spot indole test for K. oxytoca. The overall sensitivity of SCITB agar plus the spot indole test (93.3%) for the detection of K. oxytoca in stool samples was superior to that of MacConkey agar (63.3%), while the specificities were 100% and 60.4%, respectively. The former achieved a 23-fold reduction in the workload and cost of subsequent standard biochemical identifications. Cytotoxin production and the clonality of K. oxytoca were determined by a cell culture cytotoxicity neutralization assay using HEp-2 cells and pulsed-field gel electrophoresis (PFGE), respectively. Of 5,581 stool samples from 3,537 patients, K. oxytoca was cultured from 117/5,581 (2.1%) stool samples from 104/3,537 (2.9%) patients. Seventy-six of 104 (73.1%) patients with K. oxytoca had no copathogens in their diarrheal stool samples. Twenty-four (31.6%) of 76 patients carried cytotoxin-producing strains, which were significantly associated with antibiotic therapy after hospital admission (50% versus 21.2%; P = 0.01). Health care-associated diarrhea was found in 44 (42%) of 104 patients with K. oxytoca, but there was no epidemiological linkage suggestive of a nosocomial outbreak, and PFGE showed a diverse pattern. None of the patients with cytotoxin-producing K. oxytoca developed antibiotic-associated hemorrhagic colitis, suggesting that K. oxytoca can cause a mild disease manifesting as uncomplicated antibiotic-associated diarrhea with winter seasonality.

Oral immunoglobulin for the prevention of rotavirus infection in low birth weight infants

BACKGROUND

Rotavirus is a common neonatal nosocomial viral infection and epidemics with the newer P(6)G9 strains have been reported. Local mucosal immunity in the intestine to rotavirus is important in the resolution of infection and protection against subsequent infections. Oral administration of anti-rotaviral immunoglobulin preparations might be a useful strategy in preventing rotaviral infections, especially in low birth weight babies.

OBJECTIVES

To determine the effectiveness and safety of oral immunoglobulin preparations for the prevention of rotavirus infection in hospitalized low birthweight infants (birthweight < 2500 g)

SEARCH METHODS

The Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library), MEDLINE, EMBASE, CINAHL, biological Abstracts (BIOSIS), Science Citation Index for articles citing Barnes 1982 and the proceedings of the Pediatric Academic Societies from 1991 onwards were searched in July 2011. Ongoing trials were also searched at clinicaltrials.gov and controlled-trials.com

SELECTION CRITERIA

The criteria used to select studies for inclusion were: 1) design: randomized or quasi-randomized controlled trials; 2) participants: hospitalized low birthweight infants; 3) intervention: oral immunoglobulin preparations for prevention of rotavirus infection compared to placebo OR no intervention; 4) at least one of the following outcomes were reported: all cause mortality during hospital stay, mortality due to rotavirus infection during hospital stay, rotavirus infection , duration of diarrhea, need for rehydration, duration of viral excretion, duration of infection control measures, length of hospital stay in days, recurrent diarrhea or chronic diarrhea.

DATA COLLECTION AND ANALYSIS

The two review authors independently abstracted data from the included trials.

MAIN RESULTS

One published study (Barnes 1982) was eligible for inclusion in this review. Barnes 1982 found no significant difference in the rates of rotavirus infection after oral gammaglobulin versus placebo in hospitalized low birthweight babies [RR 1.27 (95% CI 0.65 to 2.37)]. In the subset of infants who became infected with rotavirus after receiving gammaglobulin or placebo for prevention of rotavirus infection, there was no significant difference in the duration of rotavirus excretion between the group who had gammaglobulin (mean 2 days, range 1 to 4 days) and the group who had placebo (mean 3 days, range 1 to 6 days). Barnes 1982 reported no adverse effects after administration of oral immunoglobulin preparations.

AUTHORS' CONCLUSIONS

Current evidence does not support the use of oral immunoglobulin preparations to prevent rotavirus infection in low birthweight infants. Researchers are encouraged to conduct well-designed neonatal trials using the newer preparations of anti-rotaviral immunoglobulins (colostrum, egg yolk immunoglobulins) and include cost effectiveness evaluations.

Oral immunoglobulin for the treatment of rotavirus diarrhea in low birth weight infants

BACKGROUND

Rotavirus infection is the most common neonatal nosocomial viral infection. It is a major health problem worldwide. Epidemics with the newer P(6)G9 strains have been reported in neonatal units globally. These strains can cause severe symptoms in most infected infants. Infection control measures become necessary and the utilization of hospital resources increase. Local mucosal immunity in the intestine to rotavirus is important in the resolution of infection and protection against subsequent infections. Boosting local immunity by oral administration of anti-rotaviral immunoglobulin preparations might be a useful strategy in treating rotaviral infections, especially in low birth weight babies.

OBJECTIVES

To determine the effectiveness and safety of oral immunoglobulin preparations for the treatment of rotavirus diarrhea in hospitalized low birth weight infants (birth weight less than 2500 g)

SEARCH STRATEGY

Electronic databases including The Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 3, 2004), MEDLINE, EMBASE and CINAHL, Biological Abstracts (BIOSIS) were searched by the strategy outlined in the protocol. Science Citation Index search for all articles that referenced Barnes 1982 were searched. The proceedings of the Pediatric Academic Societies published online at 'Abstracts Online' were searched. Ongoing registered trials at www.clinicaltrials.gov and www.controlled-trials.com were searched. Authors prominent in the field were contacted for any unpublished articles and more information on published articles was sought. Reference lists of identified clinical trials and personal files were also reviewed. The above search was updated in July 2011.

SELECTION CRITERIA

The criteria used to select studies for inclusion were: 1) DESIGN: randomized or quasi-randomized controlled trials 2) Hospitalized low birth weight infants with rotavirus diarrhea 3) INTERVENTION: Oral immunoglobulin preparations compared to placebo or no intervention 4) At least one of the following outcomes were reported: All cause mortality during hospital stay, mortality due to rotavirus infection during hospital stay, duration of diarrhea, need for rehydration, duration of viral excretion, duration of infection control measures, length of hospital stay in days, recurrent diarrhea or chronic diarrhea

DATA COLLECTION AND ANALYSIS

The two reviewers were to independently abstract data from eligible trials. No data were available for analysis.

MAIN RESULTS

No eligible randomized controlled trials were found.

AUTHORS' CONCLUSIONS

No randomized controlled trials that assessed the effectiveness or safety of oral immunoglobulin preparations for the treatment of rotavirus diarrhea in hospitalized low birth weight infants were found. Clinical trials that address the issue of oral immunoglobulin treatment of rotavirus infection are needed.

Comparison of surface sampling methods for virus recovery from fomites

The role of fomites in infectious disease transmission relative to other exposure routes is difficult to discern due, in part, to the lack of information on the level and distribution of virus contamination on surfaces. Comparisons of studies intending to fill this gap are difficult because multiple different sampling methods are employed and authors rarely report their method's lower limit of detection. In the present study, we compare a subset of sampling methods identified from a literature review to demonstrate that sampling method significantly influences study outcomes. We then compare a subset of methods identified from the review to determine the most efficient methods for recovering virus from surfaces in a laboratory trial using MS2 bacteriophage as a model virus. Recoveries of infective MS2 and MS2 RNA are determined using both a plaque assay and quantitative reverse transcription-PCR, respectively. We conclude that the method that most effectively recovers virus from nonporous fomites uses polyester-tipped swabs prewetted in either one-quarter-strength Ringer's solution or saline solution. This method recovers a median fraction for infective MS2 of 0.40 and for MS2 RNA of 0.07. Use of the proposed method for virus recovery in future fomite sampling studies would provide opportunities to compare findings across multiple studies.

Genetic variation of G4P[6] rotaviruses: evidence for novel strains circulating between the hospital and community

One hundred forty-six fecal specimens collected between 2007 and 2008 from infants with acute gastroenteritis were screened for rotavirus by ELISA with VP6-specific antibody. One hundred twenty-three of the samples (84.2%) were confirmed to be positive for group A rotavirus (community-acquired, n = 90 [73.2%] and nosocomial, n = 33 [26.8%]), and were typed subsequently using RT-PCR and sequence analysis methods. Determination of G- and P-type combinations showed that G4P[6] (78.9%) was the most common strain, followed by G3P[8] (7.3%), G1P[8] (6.5%), G2P[4] (0.8%), G2P[6] (0.8%), G1P[6] (0.8%), and G9P[8] (0.8%) strains. Of the 97 G4P[6] strains, 62 (63.8%) were responsible for community-acquired cases and 35 (36.1%) were hospital-acquired cases. Phylogenetic analysis of the VP7 gene from the G4P[6] strains revealed that both the community-acquired and nosocomial strains were segregated to the human rotaviruses circulating world-wide, including the prototype vaccinal strain, ST3, which constituted a novel sublineage in lineage 1. Owing to the recent emergence of G4P[6] rotaviruses within the hospital, as well as in the community, the findings from this study are important since they provide new information concerning the community and nosocomial spread of rotaviruses.

Rotavirus infections among HIV-infected children in Nairobi, Kenya

Human rotaviruses have emerged as a leading cause of acute diarrhea in children <5 years of age worldwide. Although there are previous reports relating to various aspects of rotaviruses, there is limited data on the involvement of rotavirus infection in HIV-infected children. We therefore evaluated the importance of rotavirus infections in HIV-related diarrhea in Kenyan children. Fecal samples were collected from a total of 207 children during the period February 1999 to June 2000 and screened for HRV antigen by enzyme-linked immunosorbent assay (ELISA). Positive samples were analyzed by VP6 subgroup specificity assay, by polyacrylamide gel electrophoresis (PAGE) and reverse transcriptase/polymerase chain reaction (RT-PCR). Fourteen percent (29/207) of the samples were positive. HIV-seropositive children with diarrhea were more likely than their counterparts without diarrhea to have rotaviruses [23.3% (10/43) versus 2.9% (2/70); p = 0.0001]. Rotavirus strain G3P[6] was predominant. These results indicate that rotavirus is an important viral etiological agent causing diarrhea in HIV-seropositive children.

Hospitalizations for nosocomial rotavirus gastroenteritis in a tertiary pediatric center: a 4-year prospective study

BACKGROUND

Although rotavirus is the most common cause of gastroenteritis worldwide, data regarding nosocomial rotavirus gastroenteritis (NRVGE) are limited. Our objectives were to study the rates, seasonality, epidemiology, and clinical features of NRVGE.

METHODS

This was a 4-year prospective study.

RESULTS

NRVGE occurred in 1% of all admissions (356/35,833), 0.8% of all hospitalization days (1164/145,595) and 0.24 cases per 100 hospitalization days. Rates of NRVGE were age-dependent, occurring in 1.8%, 1.5%, 0.3%, and 0.1% of the admissions of children age < or = 1, > 1 to 2, > 2 to 5, and > 5 years, respectively (P < .001). Of the children age > 5 years, 90% received immunosuppressive treatment or had significant underlying diseases. The number of NRVGE cases was highest in winter months, but it occurred throughout the year, and its percentage of all hospitalizations for rotavirus gastroenteritis was highest in the summer months. NRVGE occurred after a median hospitalization of 6 days, required a median hospital stay of 3 days, and warranted treatment with intravenous fluids in 67% of cases.

CONCLUSION

NRVGE is a significant health burden, especially in children age < or = 2 years, although it also can affect children age > 5 years with significant underlying disturbances. Vaccine prevention of rotavirus gastroenteritis also could reduce NRVGE and should be considered in cost-effectiveness analyses.

Identification of risk factors associated with nosocomial infection by rotavirus P4G2, in a neonatal unit of a tertiary-care hospital

A rotavirus outbreak in newborns admitted to the 'La Paz' University Hospital, Madrid was detected, followed up and controlled. Uninfected children were selected as control subjects. Samples of faeces were taken once or twice weekly from all the newborns, including those who were asymptomatic and who were admitted to the neonatal unit for early detection of rotavirus and the positive were separated from the rest of the neonates. Contact-related precautions were taken for all patients, and alcohol solutions were used for hand washing. During the months of the outbreak, 1773 children were admitted to the hospital, 131 of whom were affected by the rotavirus infection (7.4%). Of these, 72 (55%) had symptomatic infections. In the first month of the outbreak, nine cases of necrotizing enterocolitis were diagnosed (one patient developed massive intestinal necrosis). The infections (symptomatic and asymptomatic) presented a bimodal distribution caused by a new outbreak of rotavirus type P4G2 after two patients who had acquired the infection outside the hospital were admitted when the first outbreak was subsiding. The characteristics of cases and controls were analysed using bivariate and multivariate methods (non-conditional multivariate logistic regression) to identify four risk factors strongly associated with rotavirus infection: premature birth, infections other than rotavirus, malformation, and changes in glycaemia and/or presence of jaundice.

The epidemiology of human rotavirus associated with diarrhoea in Kenyan children: a review

Rotavirus gastroenteritis still remains a major cause of morbidity and mortality among young children in developing countries, with approximately 150,000-200,000 deaths occurring annually in sub-Saharan Africa. We reviewed papers published over the last 30 years on the epidemiology of rotavirus diarrhoea among the hospitalized and out-patient children in Kenya. The analysis shows rotavirus prevalence of 6-56% with diarrhoea occurring throughout the year and generally exhibiting distinct peaks during the dry months. Among the common genotype, G1 was the most predominant up to the year 2002 but more recently there has been an emergence of genotype G9 as the most predominant genotype and to a less extent G8. It is important to continue rotavirus surveillance in Kenya to determine accurately the burden of rotavirus disease and the emerging new genotypes. This will assist policy makers in decision making on rotavirus vaccine introduction and determining the impact of the vaccine.

Molecular characterization of equine rotavirus in Ireland

Group A rotaviruses are important causative agents of severe, acute dehydrating diarrhea in foals. A total of 86 rotavirus-positive fecal samples, collected from diarrheic foals from 11 counties in three of the four provinces of Ireland, were obtained from the Irish Equine Centre in Kildare during a 7-year (1999 to 2005) passive surveillance study and were characterized molecularly to establish the VP7 (G type) and VP4 (P type) antigenic specificities. Fifty-eight samples (67.5%) were found to contain G3 viruses, while in 26 samples (30.2%) the rotaviruses were typed as G14 and in 2 samples (2.3%) there was a mixed infection, G3 plus G14. All samples except for two, which were untypeable, were characterized as P[12]. Fifty-eight percent of the samples were obtained from County Kildare, the center of the Irish horse industry, where an apparent shift from G3P[12] to G14P[12] was observed in 2003. By sequence analysis of the VP7 protein, the G3 Irish strains were shown to resemble viruses of the G3A subtype (H2-like) (97.1 to 100% amino acid [aa] identity), while the G14 Irish strains displayed 93.9 to 97.1% aa identity to other G14 viruses. In the VP8* fragment of the VP4 protein, the P[12] Irish viruses displayed high conservation (92.3 to 100% aa) with other equine P[12] viruses. Worldwide, G3P[12] and G14P[12] are the most prevalent equine rotavirus strains, and G3P[12] vaccines have been developed for prevention of rotavirus-associated diarrhea in foals. Investigations of the VP7/VP4 diversity of the circulating equine viruses and the dynamics of strain replacement are important for better assessing the efficacies of the vaccines.

Group A rotavirus genotypes in Germany during 2005/2006

During the 2005/2006 winter season a total of 802 group A positive rotavirus specimens of patients from different regions throughout Germany were genotyped. Amplicons from a one-tube RT-PCR were typed by analysis of their (type-specific) size using type-specific primers, fluorescent consensus primers and a capillary sequencer for detection. While G1P[8] was predominant (45.8%), G9P[8] has emerged as the second most frequent genotype combination (37.7%). The distribution of genotypes was heterogeneous, regional frequencies regarding G1 and G9 were ranging from 15.0 to 89.3% and from 7.1 to 67.7%, respectively. Furthermore, a few human rotavirus G10P[6] and G10P[8] infections were observed.

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.

Infection control, hospital epidemiology, and patient safety

Health care-acquired are a major risk for hospitalized children. Similar to adult patients, children are vulnerable to infections related to medical devices. Children also are at significant risk of nosocomial transmission of common pediatric viral illness, such as respiratory syncytial virus and varicella. In addition, pediatric patients have unique or incompletely developed immune system.

Clinical and epidemiological aspects of rotavirus infection

Rotavirus is a major worldwide cause of infant morbidity and mortality, and disease burden in the US is substantial. Vaccination is the only practical way to gain control over rotavirus disease. Prevention through the universal use of improved live oral vaccines is on the horizon.

Use of a heminested reverse transcriptase PCR assay for detection of astrovirus in environmental swabs from an outbreak of gastroenteritis in a pediatric primary immunodeficiency unit

An outbreak of astrovirus gastroenteritis occurred in the Primary Immunodeficiency Unit at Newcastle General Hospital in March 2004. Environmental swabbing of the unit was undertaken after the outbreak, with multiple sites swabbed pre- and postcleaning. Astroviruses were detected in four environmental swabs and from two patient fecal samples using heminested reverse transcriptase PCR. An astrovirus genotype 3 strain was identified in both environmental swabs and fecal specimens and was the strain identified as being responsible for the outbreak. Environmental transmission of the virus was thought to have occurred by contamination of a syringe pump outside the laminar-flow curtain of a patient who was admitted with astrovirus gastroenteritis. This was subsequently transmitted to a cubicle next door and to a television/games console in a parents' room in the ward. Environmental monitoring of surfaces/equipment, using PCR assays for gastroenteric viruses in hospital situations where infection can give rise to serious clinical complications, may have a role in controlling and monitoring cleaning and the subsequent prevention of nosocomial transmission of gastroenteritis.

Molecular characterizations of human and animal group a rotaviruses in the Netherlands

To gain more insight into interspecies transmission of rotavirus group A, human and animal fecal samples were collected between 1997 and 2001 in The Netherlands. A total of 110 human stool samples were successfully P and G genotyped by reverse transcriptase PCR. All strains belonged to the main human rotavirus genotypes G1 to G4, G9, [P4], [P6], [P8], and [P9]. [P8]G1 was predominant, and 5.5% belonged to the G9 genotype. Eleven percent of all P[8] genotypes could be genotyped only by a recently published modified primer. Rotavirus-positive fecal samples from 28 calf herds were genotyped by DNA sequencing. Genotypes G6 and G10 predominated; G6 and G10 were detected in 22 (78.6%) and 16 (57.1%) of the rotavirus-positive calf herds, respectively. In 12 (42.9%) calf herds, we found mixed infections. Genotype G8 was not found. Genotype G6 bovine rotaviruses were divided into three clusters: UK-like, VMRI-29-like, and Hun4-like. DNA sequencing of a part of the VP7 gene was shown to be useful as a quick determination of uncommon or novel strains of which the genotyping cannot be done by genotyping PCR. Of equine strains, both VP4 and VP7 genes could be used for genotyping: two [P12]G3 and four [P12]G14 equine rotaviruses were determined. We did not find indications for rotavirus interspecies transmissions, although the recently published human G6-Hun4 is genetically related to our G6 bovine isolates. All bovine, porcine, and equine rotaviruses were within genotypes previously reported for these animal species.

Comparative efficacy of hand hygiene agents in the reduction of bacteria and viruses

Background

Health care-associated infections most commonly result from person-to-person transmission via the hands of health care workers.

Methods

We studied the efficacy of hand hygiene agents (n = 14) following 10-second applications to reduce the level of challenge organisms (Serratia marcescens and MS2 bacteriophage) from the hands of healthy volunteers using the ASTM-E-1174-94 test method.

Results

The highest log₁₀ reductions of S marcescens were achieved with agents containing chlorhexidine gluconate (CHG), triclosan, benzethonium chloride, and the controls, tap water alone and nonantimicrobial soap and water (episode 1 of hand hygiene, 1.60-2.01; episode 10, 1.60-3.63). Handwipes but not alcohol-based handrubs were significantly inferior from these agents after a single episode of hand hygiene, but both groups were significantly inferior after 10 episodes. After a single episode of hand hygiene, alcohol/silver iodide, CHG, triclosan, and benzethonium chloride were similar to the controls in reduction of MS2, but, in general, handwipes and alcohol-based handrubs showed significantly lower efficacy. After 10 episodes, only benzethonium chloride (1.33) performed as well as the controls (1.59-1.89) in the reduction of MS2.

Conclusions

Antimicrobial handwashing agents were the most efficacious in bacterial removal, whereas waterless agents showed variable efficacy. Alcohol-based handrubs compared with other products demonstrated better efficacy after a single episode of hand hygiene than after 10 episodes. Effective hand hygiene for high levels of viral contamination with a nonenveloped virus was best achieved by physical removal with a nonantimicrobial soap or tap water alone.

Rotavirus vaccines and the prevention of hospital-acquired diarrhea in children

Rotavirus, the major cause of severe acute dehydrating gastroenteritis in children less than 5 years of age, is responsible for an estimated 20-50% of all hospitalizations for diarrhea and approximately 440,000 deaths annually, primarily in the developing world. Rotavirus vaccines are considered the most promising means for disease prevention. While the prime rationale for developing rotavirus vaccines has been the enormous burden of rotavirus infection leading to severe and fatal disease, a secondary benefit may be the prevention of nosocomial rotavirus diarrhea. We have reviewed the burden of intra-hospital-acquired rotavirus infections from several countries and found that in the United States alone, as many as 25% of rotavirus hospitalizations or approximately 16,000-18,000 hospitalizations each year might be due to rotavirus infections acquired within hospitals. To countries with low rotavirus-associated mortality, prevention of these infections and the resulting economic savings therefore represent an important secondary goal. Several rotavirus vaccines are in development, and two candidates are currently being tested in large-scale safety and efficacy trials. Development of safe and effective rotavirus vaccines will protect children worldwide against the severe consequences of rotavirus infections including prolonged hospitalizations for nosocomially acquired infections.

Severe acute respiratory syndrome coronavirus on hospital surfaces

Background. Health care workers continued to contract severe acute respiratory syndrome (SARS), even after barrier precautions were widely implemented.

Methods. We explored the possible contribution of contaminated hospital surfaces to SARS transmission by swabbing surfaces in 2 hospitals and testing the swab samples by reverse-transcriptase polymerase chain reaction (RT-PCR) and viral culture.

Results. Twenty-six of 94 swab samples tested positive for viral RNA. Swab samples of respiratory secretions from each of the 4 patients examined tested positive by RT-PCR, as were 12 of 43 swabs from patient rooms and 10 of 47 swabs from other parts of the hospital, including the computer mouses at 2 nursing stations and the handrail of the public elevator. Specimens from areas with patients with SARS in the most infectious phase of illness (days 5–15 after onset) were more likely to be RNA positive than were swab specimens from elsewhere (24 of 63 samples vs. 2 of 31 samples; P = .001). All cultures showed no growth.

Conclusions. Although the viruses identified may have been noninfectious, health care workers should be aware that SARS coronavirus can contaminate environmental surfaces in the hospital, and fomites should be considered to be a possible mode of transmission of SARS.

Suivi prospectif des diarrhées nosocomiales dans 28 services de pédiatrie du quart Sud-Est de la France au cours d’un trimestre d’hiver

The aim of this study was to evaluate the risk of hospital-acquired diarrhoea during an epidemic period through a prospective multicentre observational study. A systemic investigation of the hospital-acquired diarrhoea (occurring at least 48 h after hospital admission) was conducted through a standardised questionnaire from January to March 1999 in patients of 5 years old or less hospitalised in 28 wards (620 beds) belonging to 20 hospitals located in the south-east part of France. Overall, 241 cases of hospital-acquired diarrhoea were collected, corresponding to a prevalence of 3.3% (3.6% after exclusion of patients admitted for diarrhoea) and a density of incidence of 0.81 per 100 days of hospitalisation. The mean stay duration of hospital-infected patients was greater than 10 days, versus 3.9 days for the other children (P < 0.001). A readmission was required in 27% of the infected children. Rotavirus was involved in 97.8% of microbiologically documented cases (88%). In 50% of the cases, the hospital-acquired diarrhoea was seen in patients with bronchiolitis. Contact isolation measures were prescribed in 88.4% of the cases. These results stress that hospital-acquired diarrhoea represent an important medical and economic load for paediatric units and could be used as reference data to evaluate the impact of preventive measures, especially to reduce readmission and mean stay duration.

Palestinian refugee conditions associated with intestinal parasites and diarrhoea: Nuseirat refugee camp as a case study

OBJECTIVE

To assess the socioeconomic-demographic, environmental health and hygiene conditions associated with intestinal parasites and diarrhoea in Nuseirat Refugee Camp of Gaza Strip.

METHODS

A cross-section of 1625 households were surveyed. A stratified sample was used and drawn from the eight Blocks. Face-to-face interviews were administered for data collection. Piloted and validated questionnaires along with specific checklists were used as instruments.

RESULTS

A total of 485 women interviewed (29.8%) reported intestinal parasites among their household members; 223 (13.7%) admitted cases of diarrhoea. The highest prevalence of intestinal parasites (24.1%) was found among children aged 1-4 years; the highest prevalence of diarrhoea (10.6%) was found among children younger than 1 year. Intestinal parasites were strongly associated with crowding, source of drinking water and the cleaning of water tanks, and were significantly higher among families with unclean homes. Diarrhoea was strongly associated with source of drinking water, a full-day water supply and cleaning of water tanks, and was significantly higher among families with a presence of mosquitoes and garbage around their homes.

CONCLUSIONS

Poor socioeconomic-demographic, environmental health and hygiene conditions play a major role in the occurrence of intestinal parasites and diarrhoea. Children younger than 5 years are at high risk. Real interventions, such as health education, environmental awareness, community involvement and raising funds for infrastructural development are urgently needed.

Oral immunoglobulin for the prevention of rotavirus infection in low birth weight infants

BACKGROUND

Rotavirus infection is the most common neonatal nosocomial viral infection. Epidemics with the newer P(6)G9 strains have been reported in neonatal units worldwide. These strains can cause severe symptoms in infected infants. Infection control measures become necessary and the utilisation of hospital resources increase. Local mucosal immunity in the intestine to rotavirus is important in the resolution of infection and protection against subsequent infections. Boosting local immunity by oral administration of anti-rotaviral immunoglobulin preparations might be a useful strategy in preventing rotaviral infections, especially in low birth weight babies.

OBJECTIVES

To determine the effectiveness and safety of oral immunoglobulin preparations for the prevention of rotavirus infection in hospitalised low birthweight infants (birth weight less than 2500 gms)

SEARCH STRATEGY

The Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 2, 2002), MEDLINE, EMBASE and CINAHL were searched. Science Citation Index was searched for all articles which referenced Barnes 1982. The proceedings of the Pediatric Academic Societies which were published in the journal, Pediatric Research from 1991 onwards were searched as well as abstracts of doctoral dissertations and theses from 1960 onwards. The above mentioned search strategy was completed in June 2002. Authors prominent in the field were contacted for any unpublished articles and more information on published articles was sought. Reference lists of identified clinical trials and personal files were reviewed.

SELECTION CRITERIA

The criteria used to select studies for inclusion were: 1) DESIGN: randomised or quasi-randomised controlled trials. 2) PARTICIPANTS: Hospitalised low birthweight infants. 3) INTERVENTION: Oral immunoglobulin preparations for prevention of rotavirus infection compared to placebo OR no intervention. 4) At least one of the following outcomes were reported: All cause mortality during hospital stay, mortality due to rotavirus infection during hospital stay, rotavirus infection, duration of diarrhoea, need for rehydration, duration of viral excretion, duration of infection control measures, length of hospital stay in days, recurrent diarrhoea or chronic diarrhoea.

DATA COLLECTION AND ANALYSIS

The two reviewers independently abstracted data from the included trials

MAIN RESULTS

One published study (Barnes 1982) was eligible for inclusion in this review. Two additional studies are awaiting assessment re eligibility for inclusion. Barnes 1982 found no significant difference in the rates of rotavirus infection after oral gammaglobulin versus placebo in hospitalised low birthweight babies [RR 1.27 (95% CI 0.65-2.37)]. In the subset of infants who became infected with rotavirus after receiving gammaglobulin or placebo for prevention of rotavirus infection, there was no significant difference in the duration of rotavirus excretion between the group who had gammaglobulin (mean 2 days, range 1-4 days) and the group who had placebo (mean 3 days, range 1-6 days). No adverse effects were reported by Barnes 1982 after administration of oral immunoglobulin preparations.

REVIEWER'S CONCLUSIONS

Current evidence from one randomised controlled trial does not support the routine use of oral immunoglobulin preparations for the prevention of rotavirus infection in low birth-weight infants. However, newer immunoglobulin preparations which have been found to be effective in older children have not been tested in neonatal trials. Therefore, researchers should be encouraged to conduct well designed trials in neonates at risk for rotavirus infections using the newer preparations of anti-rotaviral immunoglobulins (colostrum, egg yolk immunoglobulins). Such trials should also include cost effectiveness evaluations.

Oral immunoglobulin for the treatment of rotavirus infection in low birth weight infants

BACKGROUND

Rotavirus infection is the most common neonatal nosocomial viral infection. Epidemics with the newer P(6)G9 strains have been reported in neonatal units worldwide. These strains can cause severe symptoms in most infected infants. Infection control measures become necessary and the utilisation of hospital resources increase. Local mucosal immunity in the intestine to rotavirus is important in the resolution of infection and protection against subsequent infections. Boosting local immunity by oral administration of anti-rotaviral immunoglobulin preparations might be a useful strategy in treating rotaviral infections, especially in low birth weight babies.

OBJECTIVES

To determine the effectiveness and safety of oral immunoglobulin preparations for the treatment of rotavirus infection in hospitalised low birthweight infants (birth weight less than 2500 gms)

SEARCH STRATEGY

Electronic databases including The Cochrane Controlled Trials Register (The Cochrane Llibrary, Issue 2, 2002), MEDLINE (1966 - June 2002), EMBASE (1980 - June 2002) and CINAHL (1982 - June 2002) were searched by the strategy outlined in the protocol. Science Citation Index search for all articles which referenced Barnes 1982 were searched. The proceedings of the Pediatric Academic Societies which were published in the journal, Pediatric Research, from 1991 were searched as well as abstracts of the doctoral dissertations and theses from 1960. All of the above search strategies were completed in June 2002. Authors prominent in the field were contacted for any unpublished articles and more information on published articles was sought. Reference lists of identified clinical trials and personal files were also reviewed.

SELECTION CRITERIA

The criteria used to select studies for inclusion were: 1) DESIGN: randomised or quasi-randomised controlled trials 2) Hospitalised low birthweight infants with rotavirus infection 3) INTERVENTION: Oral immunoglobulin preparations compared to placebo OR no intervention 4) At least one of the following outcomes were reported: All cause mortality during hospital stay, mortality due to rotavirus infection during hospital stay, duration of diarrhoea, need for rehydration, duration of viral excretion, duration of infection control measures, length of hospital stay in days, recurrent diarrhoea or chronic diarrhoea

DATA COLLECTION AND ANALYSIS

The two reviewers were to independently abstract data from eligible trials. No data analysis was possible at this point.

MAIN RESULTS

No eligible randomised controlled trials were found.

REVIEWER'S CONCLUSIONS

We found no randomised controlled trials which assessed the effectiveness or safety of oral immunoglobulin preparations for the treatment of rotavirus infections in hospitalised low birthweight infants.