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Hallowell BD, Burke RM, Salas SB, Groom H, Donald JL, Mattison CP, Schmidt MA, Hall AJ. Correlates of healthcare-seeking behavior for acute gastroenteritis-United States, October 1, 2016 -September 30, 2017. PLoS One 2023; 18:e0293739. [PMID: 37906587 PMCID: PMC10617691 DOI: 10.1371/journal.pone.0293739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 10/18/2023] [Indexed: 11/02/2023] Open
Abstract
BACKGROUND In the United States, public health surveillance systems often underestimate the burden of acute gastroenteritis (AGE) because they only identify disease among those who interact with the healthcare system. OBJECTIVE To identify factors associated with healthcare-seeking behavior among individuals experiencing community-acquired AGE. METHODS From October 2016 -September 2017, we conducted a weekly, age-stratified, random sample of Kaiser Permanente Northwest members located in northwest Oregon and southwest Washington, United States. Individuals who completed the online survey and experienced AGE were included in the analysis. Univariate and multivariable logistic regressions were performed to identify predictors of healthcare-seeking behavior. RESULTS Of the 3,894 survey respondents, 395 experienced an AGE episode and were eligible for analysis, of whom, 82 (21%) sought care for their AGE episode. In the final multivariable model, individuals with a concurrent fever (odds ratio [OR]: 4.76, 95% confidence interval [95% CI]: 2.48-9.13), increased diarrhea duration (≥6 days vs 1-4 days, OR: 4.22, 95% CI: 1.78-10.03), or increased vomiting duration (≥3 days vs 1 days, OR: 2.97, 95% CI: 1.22-7.26), were significantly more likely to seek healthcare. In the adjusted model, no sociodemographic or chronic disease variables were associated with healthcare-seeking behavior. CONCLUSION These findings suggest that individuals with a short duration of AGE and those without concurrent fever are underrepresented in healthcare facility-based surveillance systems.
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Affiliation(s)
- Benjamin D. Hallowell
- Division of Viral Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
- Epidemic Intelligence Service, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Rachel M. Burke
- Division of Viral Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - S. Bianca Salas
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon, United States of America
| | - Holly Groom
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon, United States of America
| | - Judy L. Donald
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon, United States of America
| | - Claire P. Mattison
- Division of Viral Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
- Oak Ridge Institute for Science and Education, Oak Ridge, Tennessee, United States of America
| | - Mark A. Schmidt
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon, United States of America
| | - Aron J. Hall
- Division of Viral Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
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Lee BR, Harrison CJ, Hassan F, Sasidharan A, Moffatt ME, Weltmer K, Payne DC, Wikswo ME, Parashar U, Selvarangan R. A Comparison of Pathogen Detection and Risk Factors among Symptomatic Children with Gastroenteritis Compared with Asymptomatic Children in the Post-rotavirus Vaccine Era. J Pediatr 2023; 261:113551. [PMID: 37315778 DOI: 10.1016/j.jpeds.2023.113551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Revised: 05/25/2023] [Accepted: 06/06/2023] [Indexed: 06/16/2023]
Abstract
OBJECTIVE To describe demographics, pathogen distribution/seasonality, and risk factors in children seeking care for acute gastroenteritis (AGE) at a midwestern US emergency department during 5 postrotavirus vaccine years (2011-2016), and further, to compare the same data with matched healthy controls (HC). STUDY DESIGN AGE and HC participants <11 years old enrolled in the New Vaccine Surveillance Network study between December 2011 to June 2016 were included. AGE was defined as ≥3 diarrhea episodes or ≥1 vomiting episode. Each HC's age was similar to an AGE participant's age. Pathogens were analyzed for seasonality effects. Participant risk factors for AGE illness and pathogen detections were compared between HC and a matched subset of AGE cases. RESULTS One or more organisms was detected in 1159 of 2503 children (46.3%) with AGE compared with 99 of 537 HC (17.3%). Norovirus was detected most frequently among AGE (n = 568 [22.7%]) and second-most frequently in HC (n = 39 [6.8%]). Rotavirus was the second most frequently detected pathogen among AGE (n = 196 [7.8%]). Children with AGE were significantly more likely to have reported a sick contact compared with HC, both outside the home (15.6% vs 1.4%; P < .001) and inside the home (18.6% vs 2.1%; P < .001). Daycare attendance was higher among children with AGE (41.4%) compared with HC (29.5%; P < .001). The Clostridium difficile detection rate was slightly higher among HC (7.0%) than AGE (5.3%). CONCLUSIONS Norovirus was the most prevalent pathogen among children with AGE. Norovirus was detected in some HC, suggesting potential asymptomatic shedding among HC. The proportion of AGE participants with a sick contact was approximately 10 times greater than that of HC.
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Affiliation(s)
- Brian R Lee
- Children's Mercy Kansas City and University of Missouri Kansas City School of Medicine, Kansas City, MO.
| | - Christopher J Harrison
- Children's Mercy Kansas City and University of Missouri Kansas City School of Medicine, Kansas City, MO
| | - Ferdaus Hassan
- Children's Mercy Kansas City and University of Missouri Kansas City School of Medicine, Kansas City, MO
| | - Anjana Sasidharan
- Children's Mercy Kansas City and University of Missouri Kansas City School of Medicine, Kansas City, MO
| | - Mary E Moffatt
- Children's Mercy Kansas City and University of Missouri Kansas City School of Medicine, Kansas City, MO
| | - Kirsten Weltmer
- Children's Mercy Kansas City and University of Missouri Kansas City School of Medicine, Kansas City, MO
| | - Daniel C Payne
- Division of Viral Diseases, Centers for Disease Control and Prevention, Atlanta, GA
| | - Mary E Wikswo
- Division of Viral Diseases, Centers for Disease Control and Prevention, Atlanta, GA
| | - Umesh Parashar
- Division of Viral Diseases, Centers for Disease Control and Prevention, Atlanta, GA
| | - Rangaraj Selvarangan
- Children's Mercy Kansas City and University of Missouri Kansas City School of Medicine, Kansas City, MO
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Othma AAS, Gomaa HEE, El Anany MG, Abdul Rahman EM, Hassan EM, Abd Elbaky AMNE, Soliman MMS, Awadallah E. Use of multiplex PCR in diagnosis of childhood acute viral diarrhoea caused by rotavirus, norovirus, astrovirus and adenovirus in Upper Egypt. EGYPTIAN JOURNAL OF MEDICAL HUMAN GENETICS 2022. [DOI: 10.1186/s43042-022-00261-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Abstract
Background
Diarrhoea is still a major public health issue in developing countries, and it is one of the leading causes of morbidity and mortality in children. We aimed to assess the use of a multiplex reverse transcription polymerase chain reaction (RT-PCR) assay for the detection of five viruses, including rotavirus, norovirus (genogroups 1 and 2), astrovirus, and adenovirus, responsible for gastroenteritis in children under 5 years old in primary care centres in Upper Egypt.
Subjects and methods
A total of 500 stool samples were collected. Fifty samples were randomly selected for viral examination using multiplex RT-PCR for the detection of rotavirus, norovirus (genogroups 1 and 2), astrovirus, and adenovirus, causing diarrhoea.
Results
Viruses were detected in 45 (90%) of the 50 stool samples. The most frequently identified virus was norovirus G2, followed by Group A rotavirus, astrovirus and adenovirus. Mixed infection by two and three viruses was observed in 7/50 cases (14%) and 2/50 cases (4%), respectively. Norovirus G1 was not detected in the samples examined.
Conclusion
Our study reveals that multiplex PCR allows for the detection of multiple viral targets in only one reaction, rendering the assay easier to perform compared to existing testing methodologies (RT-PCR and electron microscopy). Additionally, most of the viruses were detected in summer, and the highest prevalence was in the age group less than 1 year. Norovirus G2 and rotavirus were the most frequent agents and the most common coinfections responsible for gastroenteritis in children.
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4
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Hasan H, Nasirudeen NA, Ruzlan MAF, Mohd Jamil MA, Ismail NAS, Wahab AA, Ali A. Acute Infectious Gastroenteritis: The Causative Agents, Omics-Based Detection of Antigens and Novel Biomarkers. CHILDREN (BASEL, SWITZERLAND) 2021; 8:1112. [PMID: 34943308 PMCID: PMC8700514 DOI: 10.3390/children8121112] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Revised: 11/19/2021] [Accepted: 11/22/2021] [Indexed: 12/25/2022]
Abstract
Acute infectious gastroenteritis (AGE) is among the leading causes of mortality in children less than 5 years of age worldwide. There are many causative agents that lead to this infection, with rotavirus being the commonest pathogen in the past decade. However, this trend is now being progressively replaced by another agent, which is the norovirus. Apart from the viruses, bacteria such as Salmonella and Escherichia coli and parasites such as Entamoeba histolytica also contribute to AGE. These agents can be recognised by their respective biological markers, which are mainly the specific antigens or genes to determine the causative pathogen. In conjunction to that, omics technologies are currently providing crucial insights into the diagnosis of acute infectious gastroenteritis at the molecular level. Recent advancement in omics technologies could be an important tool to further elucidate the potential causative agents for AGE. This review will explore the current available biomarkers and antigens available for the diagnosis and management of the different causative agents of AGE. Despite the high-priced multi-omics approaches, the idea for utilization of these technologies is to allow more robust discovery of novel antigens and biomarkers related to management AGE, which eventually can be developed using easier and cheaper detection methods for future clinical setting. Thus, prediction of prognosis, virulence and drug susceptibility for active infections can be obtained. Case management, risk prediction for hospital-acquired infections, outbreak detection, and antimicrobial accountability are aimed for further improvement by integrating these capabilities into a new clinical workflow.
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Affiliation(s)
- Haziqah Hasan
- Department of Pediatric, Faculty of Medicine, Universiti Kebangsaan Malaysia, Jalan Yaacob Latif, Kuala Lumpur 56000, Malaysia; (H.H.); (N.A.N.); (M.A.F.R.); (M.A.M.J.)
| | - Nor Ashika Nasirudeen
- Department of Pediatric, Faculty of Medicine, Universiti Kebangsaan Malaysia, Jalan Yaacob Latif, Kuala Lumpur 56000, Malaysia; (H.H.); (N.A.N.); (M.A.F.R.); (M.A.M.J.)
| | - Muhammad Alif Farhan Ruzlan
- Department of Pediatric, Faculty of Medicine, Universiti Kebangsaan Malaysia, Jalan Yaacob Latif, Kuala Lumpur 56000, Malaysia; (H.H.); (N.A.N.); (M.A.F.R.); (M.A.M.J.)
| | - Muhammad Aiman Mohd Jamil
- Department of Pediatric, Faculty of Medicine, Universiti Kebangsaan Malaysia, Jalan Yaacob Latif, Kuala Lumpur 56000, Malaysia; (H.H.); (N.A.N.); (M.A.F.R.); (M.A.M.J.)
| | - Noor Akmal Shareela Ismail
- Department of Biochemistry, Faculty of Medicine, Universiti Kebangsaan Malaysia, Jalan Yaacob Latif, Kuala Lumpur 56000, Malaysia;
| | - Asrul Abdul Wahab
- Department of Medical Microbiology and Immunology, Faculty of Medicine, Universiti Kebangsaan Malaysia, Jalan Yaacob Latif, Kuala Lumpur 56000, Malaysia;
| | - Adli Ali
- Department of Pediatric, Faculty of Medicine, Universiti Kebangsaan Malaysia, Jalan Yaacob Latif, Kuala Lumpur 56000, Malaysia; (H.H.); (N.A.N.); (M.A.F.R.); (M.A.M.J.)
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5
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Abdel-Rahman ME, Mathew S, Al Thani AA, Ansari KA, Yassine HM. Clinical manifestations associated with acute viral gastroenteritis pathogens among pediatric patients in Qatar. J Med Virol 2021; 93:4794-4804. [PMID: 33559912 DOI: 10.1002/jmv.26859] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 01/24/2021] [Accepted: 02/01/2021] [Indexed: 11/09/2022]
Abstract
BACKGROUND Acute gastroenteritis (AGE) remains a significant cause of diarrhea that affects children worldwide. It is usually caused by viral agents, including rotavirus (RV), norovirus (NoV), adenovirus (AdV), astrovirus (AstV), and sapovirus (SaV), and the disease severity varies accordingly. Here, we report the association of clinical severity among AGE-infected pediatrics caused by a single viral pathogen, coinfection (viral-viral), mixed infection (viral-bacterial), and AGE-negative samples. METHODS A total of 901 pediatric patients were admitted with AGE to the Pediatric Emergency Center of Hamad Medical Corporation in Qatar from June 2016 to June 2018. The age of the subjects ranged between 3 months and 14 years (median of 16 months). Virus antigens detection was performed by using Film Array Gastrointestinal (GI) Panel kit. AGE severity was assessed using the Vesikari Clinical Severity Scoring System. Multivariable multinomial logistic regression was used to model the five AGE viral agents' likelihood in relation to severity versus co-infection, mixed infection, and AGE-negative samples. RESULTS AGE was most common in pediatrics aged 1-3 years (median age = 1.25 years) and more frequent in males than females, with a ratio of 1:0.8. About 19.2% of the infections were caused by NoV, followed by RV (18.2%), AdV (6.5%), SaV (2.3%), and AstV (1.8%). The majority of viral agents were detected higher in mixed infection (32.1%) than coinfection (4.9%). Based on the Vesikari score system, severe clinical illness was recorded among pediatrics infected with RV (82.2%) and NoV (75.7%). Further on multivariable analysis, compared to testing negative, the odds of detecting RV was three times significantly higher in children with severe symptoms relative to those with moderate (adjusted-odds ratio [a-OR] = 3.10; 95% confidence interval [CI] = 1.82-5.28). Similar results were observed when considering RV relative to co-infection and mixed infection (a-OR = 2.59; 95% CI = 1.23-5.48 and a-OR = 2.06; 1.28-3.30, respectively). About one-third of the study sample were Qatari children with AGE (33%), whereas 35% and 32% were pediatrics from the Middle East and North Africa region, excluding Qatari and nonregions. CONCLUSION This study underlines the association of disease severity among AGE-infected pediatrics in Qatar. The overall Vesikari median score was significantly high, followed by more frequent hospitalization among RV-infected pediatrics compared to others. There was no reduction in the disease severity among RV-infected regardless of the vaccine dose.
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Affiliation(s)
- Manar E Abdel-Rahman
- Department of Public Health, College of Health Sciences, Qatar University, Doha, Qatar
| | - Shilu Mathew
- Biomedical Research Center and College of Health Sciences, Qatar University, Doha, Qatar
| | - Asmaa A Al Thani
- Department of Public Health, College of Health Sciences, Qatar University, Doha, Qatar
| | - Khalid Al Ansari
- Pediatric Emergency Center, Hamad Medical Corporation, Doha, Qatar
| | - Hadi M Yassine
- Department of Public Health, College of Health Sciences, Qatar University, Doha, Qatar.,Biomedical Research Center and College of Health Sciences, Qatar University, Doha, Qatar
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Cannon JL, Lopman BA, Payne DC, Vinjé J. Birth Cohort Studies Assessing Norovirus Infection and Immunity in Young Children: A Review. Clin Infect Dis 2020; 69:357-365. [PMID: 30753367 DOI: 10.1093/cid/ciy985] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Accepted: 12/10/2018] [Indexed: 02/06/2023] Open
Abstract
Globally, noroviruses are among the foremost causes of acute diarrheal disease, yet there are many unanswered questions on norovirus immunity, particularly following natural infection in young children during the first 2 years of life when the disease burden is highest. We conducted a literature review on birth cohort studies assessing norovirus infections in children from birth to early childhood. Data on infection, immunity, and risk factors are summarized from 10 community-based birth cohort studies conducted in low- and middle-income countries. Up to 90% of children experienced atleast one norovirus infection and up to 70% experienced norovirus-associated diarrhea, most often affecting children 6 months of age and older. Data from these studies help to fill critical knowledge gaps for vaccine development, yet study design and methodological differences limit comparison between studies, particularly for immunity and risk factors for disease. Considerations for conducting future birth cohort studies on norovirus are discussed.
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Affiliation(s)
- Jennifer L Cannon
- Centers for Disease Control and Prevention Foundation, Atlanta, Georgia
| | - Benjamin A Lopman
- Rollins School of Public Health, Emory University, Atlanta, Georgia
- Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Daniel C Payne
- Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Jan Vinjé
- Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
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7
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Hassan F, Kanwar N, Harrison CJ, Halasa NB, Chappell JD, Englund JA, Klein EJ, Weinberg GA, Szilagyi PG, Moffatt ME, Oberste MS, Nix WA, Rogers S, Bowen MD, Vinjé J, Wikswo ME, Parashar UD, Payne DC, Selvarangan R. Viral Etiology of Acute Gastroenteritis in <2-Year-Old US Children in the Post-Rotavirus Vaccine Era. J Pediatric Infect Dis Soc 2019; 8:414-421. [PMID: 30184153 DOI: 10.1093/jpids/piy077] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Accepted: 08/02/2018] [Indexed: 11/14/2022]
Abstract
BACKGROUND The rotavirus disease burden has declined substantially since rotavirus vaccine was introduced in the United States in 2006. The aim of this study was to determine the viral etiology of acute gastroenteritis (AGE) in US children aged <2 years. METHODS The New Vaccine Surveillance Network (NVSN) of geographically diverse US sites conducts active pediatric population-based surveillance in hospitals and emergency departments. Stool samples were collected from children aged <2 years with symptoms of AGE (n = 330) and age-matched healthy controls (HCs) (n = 272) between January and December 2012. Samples were tested by real-time reverse-transcriptase polymerase chain reaction assays {adenovirus (type 40 and 41), norovirus, parechovirus A, enterovirus, sapovirus, and astrovirus} and an enzyme immunoassay (rotavirus). All samples that tested positive were genotyped. RESULTS Detection rates of pathogens in children with AGE versus those of HCs were, respectively, 23.0% versus 6.6% for norovirus (P < .01), 23.0% versus 16.0% for adenovirus (P = .08), 11.0% versus 16.0% for parechovirus A (P = .09), 11.0% versus 9.0% for enterovirus (P = .34), 7.0% versus 3.0% for sapovirus (P = .07), 3.0% versus 0.3% for astrovirus (P = .01), and 3.0% versus 0.4% for rotavirus (P = .01). A high prevalence of adenovirus was detected at 1 surveillance site (49.0% for children with AGE and 43.0% for HCs). Norovirus GII.4 New Orleans was the most frequently detected (33.0%) norovirus genotype. Codetection of >1 virus was more common in children with AGE (16.0%) than in HCs (10.0%) (P = .03). CONCLUSIONS Norovirus, astrovirus, sapovirus, and rotavirus were detected significantly more in children with AGE than in HCs, and norovirus was the leading AGE-causing pathogen in US children aged <2 years during the year 2012.
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Affiliation(s)
- Ferdaus Hassan
- Department of Pathology and Laboratory Medicine, Children's Mercy Hospitals and Clinics, Kansas City, Missouri.,University of Missouri, School of Medicine, Kansas City
| | - Neena Kanwar
- Department of Pathology and Laboratory Medicine, Children's Mercy Hospitals and Clinics, Kansas City, Missouri
| | - Christopher J Harrison
- University of Missouri, School of Medicine, Kansas City.,Division of Infectious Diseases, Children's Mercy Hospitals and Clinics, Kansas City, Missouri
| | - Natasha B Halasa
- Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - James D Chappell
- Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Janet A Englund
- Department of Pediatrics, Seattle Children's Hospitals, Washington
| | - Eileen J Klein
- Department of Pediatrics, Seattle Children's Hospitals, Washington
| | | | - Peter G Szilagyi
- University of Rochester School of Medicine and Dentistry, New York.,Department of Pediatrics, University of California at Los Angeles
| | - Mary E Moffatt
- University of Missouri, School of Medicine, Kansas City.,Division of Emergency Medicine, Children's Mercy Hospitals and Clinics, Kansas City, Missouri
| | - M Steven Oberste
- Division of Viral Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - William A Nix
- Division of Viral Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Shannon Rogers
- Division of Viral Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Michael D Bowen
- Division of Viral Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Jan Vinjé
- Division of Viral Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Mary E Wikswo
- Division of Viral Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Umesh D Parashar
- Division of Viral Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Daniel C Payne
- Division of Viral Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Rangaraj Selvarangan
- Department of Pathology and Laboratory Medicine, Children's Mercy Hospitals and Clinics, Kansas City, Missouri.,University of Missouri, School of Medicine, Kansas City
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8
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Bierhoff M, Arvelo W, Estevez A, Bryan J, McCracken JP, López MR, López B, Parashar UD, Lindblade KA, Hall AJ. Incidence and Clinical Profile of Norovirus Disease in Guatemala, 2008-2013. Clin Infect Dis 2019; 67:430-436. [PMID: 29420688 DOI: 10.1093/cid/ciy091] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Accepted: 02/03/2018] [Indexed: 12/15/2022] Open
Abstract
Background Acute gastroenteritis (AGE) is a leading infectious cause of morbidity worldwide, particularly among children in developing countries. With the decline of rotavirus disease rates following introduction of rotavirus vaccines, the relative importance of norovirus will likely increase. Our objectives in this study were to determine the incidence and clinical profile of norovirus disease in Guatemala. Methods We analyzed data from a population-based surveillance study conducted in Guatemala from 2008 through 2013. Demographic information, clinical data, and stool samples were collected from patients who presented with AGE (≥3 liquid stools within 24 hours that initiated 7 days before presentation). Estimated incidence of hospitalized, outpatient, and total community norovirus disease was calculated using surveillance data and household surveys of healthcare use. Results We included 999 AGE hospitalizations and 3189 AGE outpatient visits at facilities, of which 164 (16%) and 370 (12%), respectively, were positive for norovirus. Severity of norovirus was milder than of rotavirus. Community incidence of norovirus ranged from 2068 to 4954 per 100000 person-years (py) in children aged<5 years. Children aged <5 years also had higher incidence of norovirus-associated hospitalization (51-105 per 100000 py) compared with patients aged ≥5 years (0-1.6 per 100000 py and 49-80 per 100000 py, respectively). Conclusions This study highlights the burden of norovirus disease in Guatemala, especially among young children. These data can help prioritize development of control strategies, including the potential use of vaccines, and provide a baseline to evaluate the impact of such interventions.
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Affiliation(s)
- Marieke Bierhoff
- Centers for Disease Control and Prevention, Atlanta, Georgia.,VU Medical Center, Amsterdam, The Netherlands
| | - Wences Arvelo
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | | | - Joe Bryan
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | | | | | | | | | - Kim A Lindblade
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Aron J Hall
- Centers for Disease Control and Prevention, Atlanta, Georgia
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9
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Chen YFE, Wang CY, Chiu CH, Kong SS, Chang YJ, Chen SY. Molecular epidemiology and clinical characteristics of norovirus gastroenteritis with seizures in children in Taiwan, 2006-2015. Medicine (Baltimore) 2019; 98:e17269. [PMID: 31577718 PMCID: PMC6783164 DOI: 10.1097/md.0000000000017269] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
This study examined the characteristics of norovirus (NoV) gastroenteritis associated with convulsions in children and its molecular epidemiology. From July 2006 through December 2015, NoV infection was confirmed by the genome detection using reverse transcriptase polymerase chain reaction. Viral genotyping with strain validation was achieved using sequence analyses with Basic Local Alignment Search Tool genome identification. The patients' clinical features were assessed retrospectively, focusing on convulsive disorders. The diagnosis of encephalitis followed the International Encephalitis Consortium. Seizures occurred in 52 (20.9%) of 249 NoV infections. GII.4 Den_Haag_2006b (n = 22, 42.3%) and GII.4 Sydney 2012 (n = 10, 19.2%) were major variants correlated with convulsions. Patient with convulsions tend to have GII.4 genotype infection (P < .001), short vomiting (≤2 days) (P < .001), and no fever (P = .002). Compared to GII.4 Den_Haag_2006b, the GII.4 Sydney 2012-associated convulsions had similar manifestations except without significant winter preponderance (P = .049). The NoV infection with convulsions had less febrile course, specific genotype (GII.4) infections, and with shorter symptom of vomiting. Continuous surveillance is important for uncommon disease associated with emerging NoV strain infections. The prevention of NoV diseases requires the development of vaccines targeting highly virulent variants.
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Affiliation(s)
- Ying Fang Elaine Chen
- Division of Neonatology, Department of Pediatrics, Taipei Medical University Shuang Ho Hospital, New Taipei City
| | - Chuan Yu Wang
- Division of Pediatric Neurology, Department of Pediatrics, Taipei Medical University Shuang Ho Hospital, New Taipei City
| | - Cheng Hsun Chiu
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Molecular Infectious Disease Research Center, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan
| | - Shu Sing Kong
- Division of Pediatric Neurology, Department of Pediatrics, Taipei Medical University Shuang Ho Hospital, New Taipei City
| | - Yi Jung Chang
- Division of Pediatric Gastroenterology, Department of Pediatrics, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan
| | - Shih Yen Chen
- Division of Pediatric Gastroenterology, Department of Pediatrics, Taipei Medical University Shuang Ho Hospital, New Taipei City, Taiwan
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10
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Abstract
Norovirus is a leading cause of childhood vomiting and diarrhea in the United States and globally. Although most illnesses caused by norovirus are self-resolving, severe outcomes may occur from dehydration, including hospitalization and death. A vast majority of deaths from norovirus occur in developing countries. Immunocompromised children are at risk for more severe outcomes. Treatment of norovirus illness is focused on early correction of dehydration and maintenance of fluid status and nutrition. Hand hygiene, exclusion of ill individuals, and environmental cleaning are important for norovirus outbreak prevention and control, and vaccines to prevent norovirus illness are currently under development.
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Affiliation(s)
- Minesh P Shah
- Division of Viral Diseases, Centers for Disease Control and Prevention, 1600 Clifton Road Northeast, Atlanta, GA 30329, USA.
| | - Aron J Hall
- Division of Viral Diseases, Centers for Disease Control and Prevention, 1600 Clifton Road Northeast, Atlanta, GA 30329, USA
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11
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Weinberg GA. Outbreak Epidemiology: One of Many New Frontiers of Norovirus Biology. J Infect Dis 2018; 219:1349-1352. [DOI: 10.1093/infdis/jiy570] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Accepted: 09/20/2018] [Indexed: 12/27/2022] Open
Affiliation(s)
- Geoffrey A Weinberg
- Department of Pediatrics, University of Rochester School of Medicine and Dentistry, New York
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12
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Haber M, Lopman BA, Tate JE, Shi M, Parashar UD. A comparison of the test-negative and traditional case-control study designs with respect to the bias of estimates of rotavirus vaccine effectiveness. Vaccine 2018; 36:5071-5076. [PMID: 29980389 DOI: 10.1016/j.vaccine.2018.06.072] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Revised: 06/15/2018] [Accepted: 06/29/2018] [Indexed: 10/28/2022]
Abstract
Estimation of the effectiveness of rotavirus vaccines via the test-negative control study design has gained popularity over the past few years. In this study design, children with severe diarrhea who test positive for rotavirus infection are considered as cases, while children who test negative serve as controls. We use a simple probability model to evaluate and compare the test-negative control and the traditional case-control designs with respect to the bias of resulting estimates of rotavirus vaccine effectiveness (VE). Comparisons are performed under two scenarios, corresponding to studies performed in high-income and low-income countries. We consider two potential sources of bias: (a) misclassification bias resulting from imperfect sensitivity and specificity of the test used to diagnose rotavirus infection, and (b) selection bias associated with possible effect of rotavirus vaccination on the probability of contracting severe non-rotavirus diarrhea. Our results suggest that both sources of bias may produce VE estimates with substantial bias. Particularly, lack of perfect specificity is associated with severe negative bias. For example, if the specificity of the diagnostic test is 90% then VE estimates from both types of case-control studies may under-estimate the true VE by more than 20%. If the vaccine protects children against non-rotavirus diarrhea then VE estimates from test-negative control studies may be close to zero even though the true VE is 50%. However, the sensitivity and specificity of the enzyme immunoassay test currently used to diagnose rotavirus infections are both over 99%, and there is no solid evidence that the existing rotavirus vaccines affect the rates of non-rotavirus diarrhea. We therefore conclude that the test-negative control study design is a convenient and reliable alternative for estimation of rotavirus VE.
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Affiliation(s)
- Michael Haber
- Department of Biostatistics and Bioinformatics, Emory University, Atlanta, GA, USA.
| | - Benjamin A Lopman
- Department of Epidemiology, Emory University, Atlanta, GA, USA; Centers for Disease Control and Prevention, Atlanta, GA, USA
| | | | - Meng Shi
- Department of Biostatistics and Bioinformatics, Emory University, Atlanta, GA, USA
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Xie J, Nettel-Aguirre A, Lee BE, Chui L, Pang XL, Zhuo R, Parsons B, Vanderkooi OG, Tarr PI, Ali S, Dickinson JA, Hagen E, Svenson LW, MacDonald SE, Drews SJ, Tellier R, Graham T, Lavoie M, MacDonald J, Freedman SB. Relationship between enteric pathogens and acute gastroenteritis disease severity: a prospective cohort study. Clin Microbiol Infect 2018; 25:454-461. [PMID: 29964235 DOI: 10.1016/j.cmi.2018.06.016] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Revised: 05/28/2018] [Accepted: 06/09/2018] [Indexed: 12/18/2022]
Abstract
OBJECTIVES To evaluate the relationship between individual bacterial and viral pathogens and disease severity. METHODS Children <18 years with three or more episodes of vomiting and/or diarrhoea were enrolled in two Canadian paediatric emergency departments between December 2014 and August 2016. Specimens were analysed employing molecular panels, and outcome data were collected 14 days after enrolment. The primary outcome was severe disease over the entire illness (symptom onset until 14-day follow-up), quantified employing the Modified Vesikari Scale (MVS) score. The score was additionally analysed in two other time periods: index (symptom onset until enrolment) and follow-up (enrolment until 14-day follow-up). RESULTS Median participant age was 20.7 (IQR: 11.3, 44.2) months; 47.4% (518/1093) and 73.4% (802/1093) of participants had index and total MVS scores ≥11, respectively. The most commonly identified pathogens were rotavirus (289/1093; 26.4%) and norovirus (258/1093; 23.6%). In multivariable analysis, severe disease over the entire illness was associated with rotavirus (OR = 9.60; 95%CI: 5.69, 16.19), Salmonella (OR = 6.61; 95%CI: 1.50, 29.17), adenovirus (OR = 2.53; 95%CI: 1.62, 3.97), and norovirus (OR = 1.43; 95%CI: 1.01, 2.01). Pathogens associated with severe disease at the index visit were: rotavirus only (OR = 6.13; 95%CI: 4.29, 8.75), Salmonella (OR = 4.59; 95%CI: 1.71, 12.29), adenovirus only (OR = 2.06; 95%CI: 1.41, 3.00), rotavirus plus adenovirus (OR = 3.15; 95%CI: 1.35, 7.37), and norovirus (OR = 0.68; 95%CI: 0.49, 0.94). During the follow-up period, rotavirus (OR = 2.21; 95%CI: 1.50, 3.25) and adenovirus (OR = 2.10; 95%CI: 1.39, 3.18) were associated with severe disease. CONCLUSIONS In children presenting for emergency department care with acute gastroenteritis, pathogens identified were predominantly viruses, and several of which were associated with severe disease. Salmonella was the sole bacterium independently associated with severe disease.
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Affiliation(s)
- J Xie
- Section of Pediatric Emergency Medicine, Alberta Children's Hospital, University of Calgary, Calgary, Alberta, Canada
| | - A Nettel-Aguirre
- Departments of Pediatrics and of Community Health Sciences, Cumming School of Medicine, Faculty of Kinesiology, Alberta Children's Hospital Research Institute, O'Brien Population Health Institute, University of Calgary, Calgary, Alberta, Canada
| | - B E Lee
- Department of Pediatrics, Faculty of Medicine and Dentistry, Women and Children's Health Research Institute, University of Alberta, Edmonton, Alberta, Canada
| | - L Chui
- Provincial Laboratory for Public Health, Alberta, Canada; Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Alberta, Canada
| | - X L Pang
- Provincial Laboratory for Public Health, Alberta, Canada; Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Alberta, Canada
| | - R Zhuo
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Alberta, Canada
| | - B Parsons
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Alberta, Canada
| | - O G Vanderkooi
- Departments of Pediatrics, Microbiology, Immunology and Infectious Diseases, Pathology and Laboratory Medicine and Community Health Sciences and the Alberta Children's Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada
| | - P I Tarr
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Washington University School of Medicine, St Louis, MO, USA
| | - S Ali
- Department of Pediatrics, Faculty of Medicine and Dentistry, Women and Children's Health Research Institute, University of Alberta, Edmonton, Alberta, Canada
| | - J A Dickinson
- Department of Family Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - E Hagen
- Section of Pediatric Emergency Medicine, Alberta Children's Hospital, University of Calgary, Calgary, Alberta, Canada
| | - L W Svenson
- Analytics and Performance Reporting, Alberta Health Division of Preventive Medicine, School of Public Health, University of Alberta, Edmonton, Alberta, Canada
| | - S E MacDonald
- Faculty of Nursing, University of Alberta, Edmonton, Canada; School of Public Health, University of Alberta, Edmonton, Canada; Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - S J Drews
- Provincial Laboratory for Public Health, Alberta, Canada; Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Alberta, Canada
| | - R Tellier
- Provincial Laboratory for Public Health, Alberta, Canada; Departments of Pathology and Laboratory Medicine and Microbiology, Immunology and Infectious Diseases, University of Calgary, Calgary, Alberta, Canada
| | - T Graham
- Alberta Health Services, Edmonton Zone, Alberta, Canada; Department of Emergency Medicine, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - M Lavoie
- Population and Public Health, Fraser Health, Surrey, British Columbia, Canada
| | - J MacDonald
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - S B Freedman
- Sections of Pediatric Emergency Medicine and Gastroenterology, Alberta Children's Hospital, Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.
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Abstract
BACKGROUND Rotaviruses (RVs) and noroviruses (NoVs) are the most common causes of severe acute gastroenteritis in children. It is generally accepted that RVs cause severe acute gastroenteritis in a higher proportion of cases compared with NoVs. To our knowledge, there are no systematic reviews and meta-analyses comparing the severity of NoV and RV disease. METHODS We searched MEDLINE for studies reporting data for NoV and RV medically attended disease severity in children. We included studies where all children had been tested for both NoV (reverse transcription polymerase chain reaction) and RV (enzyme-linked immunosorbent assay or reverse transcription polymerase chain reaction) and that reported disease severity using the Vesikari or modified Vesikari score, or provided clinical information on severity. We generated pooled estimates of the mean with 95% confidence intervals using random effects meta-analysis. RESULTS We identified 266 publications, of which 31 were retained for qualitative analysis and 26 for quantitative analysis. Fourteen studies provided data on severity score for the meta-analysis. The pooled mean severity scores (95% confidence interval) among outpatients were 10 (8-12) and 11 (8-14) for NoV and RV, respectively. Among inpatients, they were 11 (9-13) for NoV and 12 (10-14) for RV. The difference was statistically significant among inpatients, but relatively small (1 point in a 20-point scale). About 20% more children with RV required rehydration when compared with children with NoV. CONCLUSIONS NoV causes moderate to severe disease similar to RV in young children. This information should be useful for future evaluations of an eventual introduction of NoV vaccines in national immunization programs.
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Chhabra P, Gregoricus N, Weinberg GA, Halasa N, Chappell J, Hassan F, Selvarangan R, Mijatovic-Rustempasic S, Ward ML, Bowen M, Payne DC, Vinjé J. Comparison of three multiplex gastrointestinal platforms for the detection of gastroenteritis viruses. J Clin Virol 2017; 95:66-71. [PMID: 28889082 DOI: 10.1016/j.jcv.2017.08.012] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2017] [Revised: 08/22/2017] [Accepted: 08/25/2017] [Indexed: 02/04/2023]
Abstract
BACKGROUND Viruses are major etiological agents of childhood gastroenteritis. In recent years, several molecular platforms for the detection of viral enteric pathogens have become available. OBJECTIVE/STUDY DESIGN We evaluated the performance of three multiplex platforms including Biofire's Gastrointestinal Panel (FilmArray), Luminex xTAG® Gastrointestinal Pathogen Panel (GPP), and the TaqMan Array Card (TAC) for the detection of five gastroenteritis viruses using a coded panel of 300 archived stool samples. RESULTS The FilmArray detected a virus in 199 (96.1%) and the TAC in 172 (83.1%) of the 207 samples (187 samples positive for a single virus and 20 samples positive for more than one virus) whereas the GPP detected a virus in 100 (78.7%) of the 127 (97 positive for one virus and three positive for more than one virus) samples. Overall the clinical accuracy was highest for the FilmArray (98%) followed by TAC (97.2%) and GPP (96.9%). The sensitivity of the FilmArray, GPP and TAC platforms was highest for rotavirus (100%, 95.8%, and 89.6%, respectively) and lowest for adenovirus type 40/41 (97.4%, 57.9% and 68.4%). The specificity of the three platforms ranged from 95.6% (rotavirus) to 99.6% (norovirus/sapovirus) for the FilmArray, 99.6% (norovirus) to 100% (rotavirus/adenovirus) for GPP, and 98.9% (astrovirus) to 100% (rotavirus/sapovirus) for TAC. CONCLUSION The FilmArray demonstrated the best analytical performance followed by TAC. In recent years, the availability of multi-enteric molecular testing platforms has increased significantly and our data highlight the strengths and weaknesses of these platforms.
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Affiliation(s)
- Preeti Chhabra
- Synergy America, Inc., Atlanta, GA, United States; Division of Viral Diseases, National Center for Immunizations and Respiratory Disease, Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Nicole Gregoricus
- Division of Viral Diseases, National Center for Immunizations and Respiratory Disease, Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Geoffrey A Weinberg
- University of Rochester School of Medicine and Dentistry, Golisano Children's Hospital, Rochester, NY, United States
| | - Natasha Halasa
- Department of Pediatrics, Vanderbilt Vaccine Research Program, Vanderbilt University Medical Center, Nashville, TN, United States
| | - James Chappell
- Department of Pediatrics, Vanderbilt Vaccine Research Program, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Ferdaus Hassan
- Department of Pathology and Laboratory Medicine, Children's Mercy Hospitals, Kansas City, MO, United States
| | - Rangaraj Selvarangan
- Department of Pathology and Laboratory Medicine, Children's Mercy Hospitals, Kansas City, MO, United States
| | - Slavica Mijatovic-Rustempasic
- Division of Viral Diseases, National Center for Immunizations and Respiratory Disease, Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - M Leanne Ward
- Division of Viral Diseases, National Center for Immunizations and Respiratory Disease, Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Michael Bowen
- Division of Viral Diseases, National Center for Immunizations and Respiratory Disease, Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Daniel C Payne
- Division of Viral Diseases, National Center for Immunizations and Respiratory Disease, Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Jan Vinjé
- Division of Viral Diseases, National Center for Immunizations and Respiratory Disease, Centers for Disease Control and Prevention, Atlanta, GA, United States.
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16
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Kim A, Chang JY, Shin S, Yi H, Moon JS, Ko JS, Oh S. Epidemiology and Factors Related to Clinical Severity of Acute Gastroenteritis in Hospitalized Children after the Introduction of Rotavirus Vaccination. J Korean Med Sci 2017; 32:465-474. [PMID: 28145650 PMCID: PMC5290106 DOI: 10.3346/jkms.2017.32.3.465] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Accepted: 11/19/2016] [Indexed: 12/18/2022] Open
Abstract
We aimed to investigate epidemiology and host- and pathogen-related factors associated with clinical severity of acute gastroenteritis (AGE) in children after rotavirus vaccination introduction. Factors assessed included age, co-infection with more than 2 viruses, and virus-toxigenic Clostridium difficile co-detection. Fecal samples and clinical information, including modified Vesikari scores, were collected from hospitalized children with AGE. The presence of enteric viruses and bacteria, including toxigenic C. difficile, was detected by polymerase chain reaction (PCR). Among the 415 children included, virus was detected in stool of 282 (68.0%) children. Co-infection with more than 2 viruses and toxigenic C. difficile were found in 24 (8.5%) and 26 (9.2%) children with viral AGE, respectively. Norovirus (n = 130) infection, including norovirus-associated co-infection, was the most frequent infection, especially in children aged < 24 months (P < 0.001). In the severity-related analysis, age < 24 months was associated with greater diarrheal severity (P < 0.001) and modified Vesikari score (P = 0.001), after adjustment for other severity-related factors including rotavirus status. Although the age at infection with rotavirus was higher than that for other viruses (P = 0.001), rotavirus detection was the most significant risk factor for all severity parameters, including modified Vesikari score (P < 0.001). Viral co-infection and toxigenic C. difficile co-detection were not associated with any severity-related parameter. This information will be helpful in the management of childhood AGE in this era of rotavirus vaccination and availability of molecular diagnostic tests, which often lead to the simultaneous detection of multiple pathogens.
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Affiliation(s)
- Ahlee Kim
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Ju Young Chang
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
- Department of Pediatrics, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, Korea.
| | - Sue Shin
- Department of Laboratory Medicine, Seoul National University College of Medicine, Seoul, Korea
- Department of Laboratory Medicine, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, Korea
| | - Hana Yi
- School of Biosystem and Biomedical Science, Korea University College of Health Science, Seoul, Korea
| | - Jin Soo Moon
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Jae Sung Ko
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Sohee Oh
- Department of Medical Statistics, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, Korea
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17
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Norovirus infections in young children in Lusaka Province, Zambia: clinical characteristics and molecular epidemiology. BMC Infect Dis 2017; 17:92. [PMID: 28114885 PMCID: PMC5260028 DOI: 10.1186/s12879-017-2206-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2016] [Accepted: 01/16/2017] [Indexed: 12/12/2022] Open
Abstract
Background The burden, clinical features, and molecular epidemiology of norovirus infection in young children in southern Africa are not well defined. Methods Using data from a health facility-based surveillance study of children <5 years in Lusaka Province, Zambia presenting with diarrhea, we assessed the burden of norovirus infection. A convenience sample of 454 stool specimens was tested for norovirus using reverse-transcriptase polymerase chain reaction (RT-PCR). RT-PCR positive samples underwent additional nucleotide sequencing for genogroup and genotype identification. Clinical features and severity of diarrheal illnesses were compared between norovirus-positive and -negative subjects using Chi-squared and t-tests. Results Norovirus was detected in 52/454 (11.5%) specimens tested. Abdominal pain, fever, and vomiting were the most common presenting features in norovirus-associated illnesses. However, there were no significant differences in the clinical features of norovirus-positive compared to norovirus-negative illnesses. Of 43 isolates that were available for sequencing, 31 (72.1%) were genogroup II (GII) and 12 (27.9%) were genogroup I (GI). The distribution of genotypes was diverse. Conclusions Noroviruses were detected in approximately 10% of young children with diarrhea in the Lusaka Province of Zambia, with GII representing the majority of infections. These findings support the role of norovirus in symptomatic diarrhea disease in Africa. Further studies are needed to confirm these observations and to evaluate prevention strategies. Electronic supplementary material The online version of this article (doi:10.1186/s12879-017-2206-2) contains supplementary material, which is available to authorized users.
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18
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Doll MK, Morrison KT, Buckeridge DL, Quach C. Two Birds With One Stone: Estimating Population Vaccination Coverage From a Test-negative Vaccine Effectiveness Case-control Study. Clin Infect Dis 2016; 63:1080-1086. [PMID: 27313264 DOI: 10.1093/cid/ciw397] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Accepted: 06/09/2016] [Indexed: 02/02/2023] Open
Abstract
Vaccination program evaluation includes assessment of vaccine uptake and direct vaccine effectiveness (VE). Often examined separately, we propose a design to estimate rotavirus vaccination coverage using controls from a rotavirus VE test-negative case-control study and to examine coverage following implementation of the Quebec, Canada, rotavirus vaccination program. We present our assumptions for using these data as a proxy for coverage in the general population, explore effects of diagnostic accuracy on coverage estimates via simulations, and validate estimates with an external source. We found 79.0% (95% confidence interval, 74.3%, 83.0%) ≥2-dose rotavirus coverage among participants eligible for publicly funded vaccination. No differences were detected between study and external coverage estimates. Simulations revealed minimal bias in estimates with high diagnostic sensitivity and specificity. We conclude that controls from a VE case-control study may be a valuable resource of coverage information when reasonable assumptions can be made for estimate generalizability; high rotavirus coverage demonstrates success of the Quebec program.
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Affiliation(s)
- Margaret K Doll
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University
| | - Kathryn T Morrison
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University
| | - David L Buckeridge
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University
| | - Caroline Quach
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University.,Department of Pediatrics, Division of Infectious Diseases, The Montreal Children's Hospital.,Vaccine Study Centre, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
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Pringle K, Lopman B, Vega E, Vinje J, Parashar UD, Hall AJ. Noroviruses: epidemiology, immunity and prospects for prevention. Future Microbiol 2015; 10:53-67. [PMID: 25598337 DOI: 10.2217/fmb.14.102] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
In recent years, noroviruses have become recognized as an important cause of both sporadic and epidemic acute gastroenteritis (AGE), largely due to the improved availability of broadly reactive real-time RT-PCR (TaqMan-based RT-PCR) assays. While there is substantial diversity among noroviruses, one specific genotype, GII.4, is the most common etiology in sporadic and epidemic AGE. Outbreaks of norovirus AGE most commonly occur in healthcare facilities and restaurants and result in significant morbidity and mortality and substantial healthcare costs. Norovirus vaccine development is progressing, and Phase I and II human trials have shown proof-of-principle that norovirus vaccines can reduce illness and infection.
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Affiliation(s)
- Kimberly Pringle
- Division of Viral Diseases, National Center for Immunization & Respiratory Diseases, Centers for Disease Control & Prevention, 1600 Clifton Road, Mailstop A-34, Atlanta, GA, 30333, USA
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20
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Chen CJ, Wu FT, Huang YC, Chang WC, Wu HS, Wu CY, Lin JS, Huang FC, Hsiung CA. Clinical and Epidemiologic Features of Severe Viral Gastroenteritis in Children: A 3-Year Surveillance, Multicentered Study in Taiwan With Partial Rotavirus Immunization. Medicine (Baltimore) 2015; 94:e1372. [PMID: 26287425 PMCID: PMC4616446 DOI: 10.1097/md.0000000000001372] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
The global epidemiological landscape of childhood acute gastroenteritis (AGE) is changing after the introduction of 2 effective rotavirus vaccines in 2006. A comprehensive evaluation for viral etiology of childhood AGE in Taiwan, where rotavirus vaccination was provided by the private sector since 2006, is lacking.From 2009 to 2011, children younger than 5 years of age with AGE who were hospitalized at 3 sentinel hospitals were enrolled in this surveillance study. Stool specimens were tested for rotavirus, norovirus, enteric adenovirus, and astrovirus. The epidemiologic and clinical information was collected by questionnaire-based interviews and chart reviews.Viral agents were detected in 1055 (37.5%) of 2810 subjects, with rotavirus (21.2%) being the leading cause of disease, followed by norovirus (14.9%), enteric adenovirus (3.74%), astrovirus (2.10%), and a mixture of at least 2 of 4 above-mentioned viruses (4.06%). The majority (56%) of the viral AGE occurred in children <2 years of age. Rotavirus and norovirus were detected more frequently in cool seasons (P < 0.0001 for both), whereas no seasonal variation was observed for adenovirus and astrovirus. Adult households with diarrhea and a Vesikari score >10 were independent factors respectively associated with an increased risk of norovirus (adjusted odds ratio [aOR] 9.034, P = 0.0003) and rotavirus (aOR, 3.284, P < 0.0001) infections. Rotavirus immunization and female gender were protective factors against rotavirus (aOR, 0.198, P < 0.0001) and astrovirus (aOR, 0.382, P = 0.0299) infections, respectively.Rotavirus and norovirus are the 2 most important viral agents of childhood AGE in Taiwan with partial rotavirus immunization. In addition, different enteric viruses are associated with distinct epidemiologic and clinical features.
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Affiliation(s)
- Chih-Jung Chen
- From the Division of Pediatric Infectious Diseases, Department of Pediatrics, Chang Gung Memorial Hospital, Kweishan, Taoyuan, Taiwan, ROC (C-JC, Y-CH); Chang Gung University College of Medicine, Kweishan, Taoyuan, Taiwan, ROC (C-JC, Y-CH); Center for Research, Diagnostics and Vaccine Development, Centers for Disease Control, Taipei, Taiwan, ROC (F-TW, H-SW, C-YW); Institute of Population Health Sciences, National Health Research Institutes, Miaoli, Taiwan, ROC (W-CC, CAH); Department of Laboratory Medicine, Changhua Christian Hospital, Changhua, Taiwan, ROC (J-SL); and Department of Pediatrics, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan, ROC (F-CH)
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21
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Freedman SB, Lee BE, Louie M, Pang XL, Ali S, Chuck A, Chui L, Currie GR, Dickinson J, Drews SJ, Eltorki M, Graham T, Jiang X, Johnson DW, Kellner J, Lavoie M, MacDonald J, MacDonald S, Svenson LW, Talbot J, Tarr P, Tellier R, Vanderkooi OG. Alberta Provincial Pediatric EnTeric Infection TEam (APPETITE): epidemiology, emerging organisms, and economics. BMC Pediatr 2015; 15:89. [PMID: 26226953 PMCID: PMC4521468 DOI: 10.1186/s12887-015-0407-7] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2015] [Accepted: 07/15/2015] [Indexed: 01/05/2023] Open
Abstract
Background Each year in Canada there are 5 million episodes of acute gastroenteritis (AGE) with up to 70 % attributed to an unidentified pathogen. Moreover, 90 % of individuals with AGE do not seek care when ill, thus, burden of disease estimates are limited by under-diagnosing and under-reporting. Further, little is known about the pathogens causing AGE as the majority of episodes are attributed to an “unidentified” etiology. Our team has two main objectives: 1) to improve health through enhanced enteric pathogen identification; 2) to develop economic models incorporating pathogen burden and societal preferences to inform enteric vaccine decision making. Methods/Design This project involves multiple stages: 1) Molecular microbiology experts will participate in a modified Delphi process designed to define criteria to aid in interpreting positive molecular enteric pathogen test results. 2) Clinical data and specimens will be collected from children aged 0–18 years, with vomiting and/or diarrhea who seek medical care in emergency departments, primary care clinics and from those who contact a provincial medical advice line but who do not seek care. Samples to be collected will include stool, rectal swabs (N = 2), and an oral swab. Specimens will be tested employing 1) stool culture; 2) in-house multiplex (N = 5) viral polymerase chain reaction (PCR) panel; and 3) multi-target (N = 15) PCR commercially available array. All participants will have follow-up data collected 14 days later to enable calculation of a Modified Vesikari Scale score and a Burden of Disease Index. Specimens will also be collected from asymptomatic children during their well child vaccination visits to a provincial public health clinic. Following the completion of the initial phases, discrete choice experiments will be conducted to enable a better understanding of societal preferences for diagnostic testing and vaccine policy. All of the results obtained will be integrated into economic models. Discussion This study is collecting novel samples (e.g., oral swabs) from previously untested groups of children (e.g., those not seeking medical care) which are then undergoing extensive molecular testing to shed a new perspective on the epidemiology of AGE. The knowledge gained will provide the broadest understanding of the epidemiology of vomiting and diarrhea of children to date.
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Affiliation(s)
- Stephen B Freedman
- Department of Pediatrics, Sections of Pediatric Emergency Medicine and Gastroenterology, Alberta Children's Hospital, Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada.
| | - Bonita E Lee
- Department of Pediatrics, Stollery Children's Hospital, University of Alberta, Edmonton, AB, Canada.
| | - Marie Louie
- Provincial Laboratory for Public Health (ProvLab, Alberta Health Services), Departments of Microbiology, Immunology & Infectious Disease and Pathology & Laboratory Medicine, University of Calgary, Calgary, AB, Canada.
| | - Xiao-Li Pang
- Department of Laboratory Medicine & Pathology, University of Alberta, Edmonton, AB, Canada.
| | - Samina Ali
- Department of Pediatrics & Emergency Medicine, University of Alberta, Faculty of Medicine & Dentistry, Women and Children's Health Research Institute, Stollery Children's Hospital, Edmonton, AB, Canada.
| | - Andy Chuck
- Institute of Health Economics, Edmonton, AB, Canada.
| | - Linda Chui
- University of Alberta, Edmonton, AB, Canada.
| | - Gillian R Currie
- Department of Pediatrics, Alberta Children's Hospital Research Institute, O'Brien Institute of Public Health, University of Calgary, Calgary, AB, Canada. .,Department of Community Health Sciences, Alberta Children's Hospital Research Institute, O'Brien Institute of Public Health, University of Calgary, Calgary, AB, Canada.
| | - James Dickinson
- Departments of Family Medicine and Community Health Sciences, University of Calgary, Calgary, AB, Canada.
| | - Steven J Drews
- Department of Laboratory Medicine & Pathology, University of Alberta, Edmonton, AB, Canada.
| | - Mohamed Eltorki
- Department of Pediatrics, Section of Pediatric Emergency Medicine, Alberta Children's Hospital, University of Calgary, Calgary, AB, Canada.
| | - Tim Graham
- Department of Emergency Medicine, University of Alberta, Edmonton, AB, Canada.
| | - Xi Jiang
- Division of Infectious Diseases, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, USA.
| | - David W Johnson
- Departments of Pediatrics and Physiology and Pharmacology, Section of Pediatric Emergency Medicine, Alberta Children's Hospital, Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada.
| | - James Kellner
- Department of Pediatrics, Section of Infectious Diseases, Alberta Children's Hospital, Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada.
| | - Martin Lavoie
- Alberta Health, University of Alberta, Edmonton, AB, Canada.
| | - Judy MacDonald
- Alberta Health Services, Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada.
| | - Shannon MacDonald
- Department of Pediatrics, University of Calgary, Edmonton, AB, Canada. .,Faculty of Nursing, University of Alberta, Edmonton, AB, Canada.
| | | | - James Talbot
- Alberta Health, University of Alberta, Edmonton, AB, Canada.
| | - Phillip Tarr
- Division of Gastroenterology, Washington University, St. Louis, MO, USA.
| | - Raymond Tellier
- Department of Microbiology, Immunology and Infectious Disease, University of Calgary, Calgary, AB, Canada.
| | - Otto G Vanderkooi
- Department of Pediatrics, Section of Infectious Diseases, Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada. .,Department of Pathology and Laboratory Medicine, Section of Microbiology, Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada. .,Department of Microbiology, Immunology & Infectious Diseases, Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada.
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22
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Mirelman AJ, Ballard SB, Saito M, Kosek MN, Gilman RH. Cost-effectiveness of norovirus vaccination in children in Peru. Vaccine 2015; 33:3084-91. [PMID: 25980428 DOI: 10.1016/j.vaccine.2015.05.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Revised: 04/28/2015] [Accepted: 05/04/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND With candidate norovirus (NV) vaccines in a rapid phase of development, assessment of the potential economic value of vaccine implementation will be necessary to aid health officials in vaccine implementation decisions. To date, no evaluations have been performed to evaluate the benefit of adopting NV vaccines for use in the childhood immunization programs of low- and middle-income countries. METHODS We used a Markov decision model to evaluate the cost-effectiveness of adding a two-dose NV vaccine to Peru's routine childhood immunization schedule using two recent estimates of NV incidence, one for a peri-urban region and one for a jungle region of the country. RESULTS Using the peri-urban NV incidence estimate, the annual cost of vaccination would be $13.0 million, offset by $2.6 million in treatment savings. Overall, this would result in 473 total DALYs averted; 526,245 diarrhea cases averted;153,735 outpatient visits averted; and 414 hospitalizations averted between birth and the fifth year of life. The incremental cost-effectiveness ratio would be $21,415 per DALY averted; $19.86 per diarrhea case; $68.23 per outpatient visit; and $26,298 per hospitalization. Using the higher jungle NV incidence rates provided a lower cost per DALY of $10,135. The incremental cost per DALY with per-urban NV incidence is greater than three times the 2012 GDP per capita of Peru but the estimate drops below this threshold using the incidence from the jungle setting. In addition to the impact of incidence, sensitivity analysis showed that vaccine price and efficacy play a strong role in determining the level of cost-effectiveness. CONCLUSIONS The introduction of a NV vaccine would prevent many healthcare outcomes in the Peru and potentially be cost-effective in scenarios with high NV incidence. The vaccine cost-effectiveness model could also be applied to the evaluation of NV vaccine cost-effectiveness in other countries. In resource-poor settings, where NV incidence rates are expected to be higher.
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Affiliation(s)
- Andrew J Mirelman
- Centre for Health Economics, University of York, Heslington, United Kingdom
| | - Sarah Blythe Ballard
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
| | - Mayuko Saito
- Department of Virology, Tohoku University Graduate School of Medicine, Sendai, Japan; Asociación Benéfica PRISMA, Lima, Peru
| | - Margaret N Kosek
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Robert H Gilman
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Laboratorios de Investigación y Desarrollo, Universidad Peruana Cayetano Heredia, Lima, Peru
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23
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Belliot G, Lopman BA, Ambert-Balay K, Pothier P. The burden of norovirus gastroenteritis: an important foodborne and healthcare-related infection. Clin Microbiol Infect 2015; 20:724-30. [PMID: 24943671 DOI: 10.1111/1469-0691.12722] [Citation(s) in RCA: 72] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Human norovirus (NoV) is now recognized as one of the most important causative agents of gastroenteritis in all age groups worldwide. During the course of NoV infection, symptoms are usually mild and disappear within 48 h after onset. The incidence of NoV infection is high, with hundreds of cases per 10 000 of the population, although the number of infections is still underestimated. Epidemiological surveys conducted in Europe and North America have shown that NoV infections constitute a major disease burden, especially for young children and the elderly, in whom NoV infection leads to high rates of hospitalization and mortality. NoV infections are also of concern in hospitals, where viral infections can be persistent in immunocompromised patients. Although the cost of NoV infection in the hospital community has not yet been clearly established, it appears that NoV infections could cost hundreds of thousands of euros in terms of unit closure, and NoV-related sickness in patients and health workers. Besides their clinical burden, NoVs, as foodborne pathogens, also cause to millions of dollars of losses for the healthcare system and the food industry. Recent estimates in the USA showed that, annually, NoV illness cost $2 billion and led to a loss of approximately 5000 quality-adjusted life-years, making NoV one of the top five pathogens causing enteric illnesses. The highest cost among 14 foodborne pathogens is also attributed to human NoV in The Netherlands. This accumulation of evidence underlines the enormous impact of NoV on populations.
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Affiliation(s)
- G Belliot
- Laboratory of Virology, National Reference Centre for Enteric Viruses, Public Hospital of Dijon, Dijon, France
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24
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Amaral MSC, Estevam GK, Penatti M, Lafontaine R, Lima ICG, Spada PKP, Gabbay YB, Matos NB. The prevalence of norovirus, astrovirus and adenovirus infections among hospitalised children with acute gastroenteritis in Porto Velho, state of Rondônia, western Brazilian Amazon. Mem Inst Oswaldo Cruz 2015; 110:215-21. [PMID: 25946245 PMCID: PMC4489452 DOI: 10.1590/0074-02760140381] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2014] [Accepted: 01/12/2015] [Indexed: 01/10/2023] Open
Abstract
Although viruses are well-established causes of acute gastroenteritis, few data on the circulation of these pathogens in Porto Velho, state of Rondônia, Brazil, are available. Thus, faecal samples from hospitalised diarrhoeic children, under six years of age, were collected and tested for the presence of norovirus (NoV), adenovirus (AdV) and astrovirus (AstV) from February 2010-February 2012. Specimens were screened by reverse-transcription polymerase chain reaction and viruses were found in 10.7% (63/591) of the cases. NoV, AdV and AstV were detected in 7.8%, 2% and 0.8% of the samples, respectively. NoV infection was observed at all ages and was most prevalent in zero-18-month-old children (84.7%; p = 0.002). A higher incidence of NoV was detected from February-April 2010, when it was found in 52.2% of the cases. Co-infections involving these viruses, rotavirus and enteropathogenic bacteria were detected in 44.4% (28/63) of the children with viral diarrhoea. Nosocomial infections were demonstrated in 28.6% (18/63) of the cases in which viruses were detected. The present paper reports, for the first time, the circulation of NoV and AstV among the paediatric population of Porto Velho and it contributes to our understanding of the roles of these pathogens in gastrointestinal infections.
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Affiliation(s)
| | | | - Marilene Penatti
- Hospital Infantil Cosme e Damião, Secretaria de Estado da Saúde, Porto Velho, RO, Brasil
| | - Roger Lafontaine
- Centro de Pesquisa em Medicina Tropical, Porto Velho, RO, Brasil
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25
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Parra M, Herrera D, Jácome MF, Mesa MC, Rodríguez LS, Guzmán C, Angel J, Franco MA. Circulating rotavirus-specific T cells have a poor functional profile. Virology 2014; 468-470:340-350. [PMID: 25238642 DOI: 10.1016/j.virol.2014.08.020] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2014] [Revised: 05/12/2014] [Accepted: 08/21/2014] [Indexed: 10/24/2022]
Abstract
Frequencies of circulating T cells producing IFN-γ, TNF-α, and IL-2, and percentages of T cells proliferating after stimulation with rotavirus (RV), tetanus toxoid, and influenza were evaluated in PBMC derived from healthy adults and children. In addition, the potential anergic state of RV-specific T cells was analyzed by stimulation of PBMC with RV antigen in the presence of three anergy inhibitors (rIL-2, rIL-12, or DGKα-i). The quality and magnitude of RV-T cell responses were significantly lower than those of tetanus toxoid and influenza antigens. RV-CD4 T cell response was enriched in monofunctional IFN-γ(+) cells, while influenza-CD4 and tetanus toxoid-CD4 T cell responses were enriched in multifunctional T cells. Moreover, rIL-2--unlike rIL-12 or DGKα-i--increased the frequencies of RV-CD4 TNF-α(+), CD4 IFN-γ(+), and CD8 IFN-γ(+) cells. Thus, circulating RV-T cells seem to have a relatively poor functional profile that may be partially reversed in vitro by the addition of rIL-2.
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Affiliation(s)
- Miguel Parra
- Instituto de Genética Humana, Facultad de Medicina, Pontificia Universidad Javeriana, Pontificia Universidad Javeriana, Carrera 7 # 40-62, Bogotá, Colombia
| | - Daniel Herrera
- Instituto de Genética Humana, Facultad de Medicina, Pontificia Universidad Javeriana, Pontificia Universidad Javeriana, Carrera 7 # 40-62, Bogotá, Colombia
| | - María Fernanda Jácome
- Departamento de Microbiología, Facultad de Ciencias, Pontificia Universidad Javeriana, Bogotá, Colombia
| | - Martha C Mesa
- Departamento de Microbiología, Facultad de Ciencias, Pontificia Universidad Javeriana, Bogotá, Colombia
| | - Luz-Stella Rodríguez
- Instituto de Genética Humana, Facultad de Medicina, Pontificia Universidad Javeriana, Pontificia Universidad Javeriana, Carrera 7 # 40-62, Bogotá, Colombia
| | - Carolina Guzmán
- Departamento de Pediatría, Hospital Universitario San Ignacio, Facultad de Medicina, Pontificia Universidad Javeriana, Bogotá, Colombia
| | - Juana Angel
- Instituto de Genética Humana, Facultad de Medicina, Pontificia Universidad Javeriana, Pontificia Universidad Javeriana, Carrera 7 # 40-62, Bogotá, Colombia
| | - Manuel A Franco
- Instituto de Genética Humana, Facultad de Medicina, Pontificia Universidad Javeriana, Pontificia Universidad Javeriana, Carrera 7 # 40-62, Bogotá, Colombia
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