A Clinical and Epidemiological Study of Enterovirus Associated Diarrhea in Hospitalized Children
Background: Diarrhea is a leading cause of morbidity and mortality in children less than five years of age. The etiology of diarrhea is unknown in nearly 40% of the cases. Enterovirus as a cause of diarrhea is well known, but there are few studies till date focusing on the epidemiological and clinical variables. Objectives: To determine the prevalence and seasonal variation and to study the clinical profile and course of enterovirus associated diarrhea in children up to five years of age. Methods: A hospital based prospective study was carried out at Vanivilas Childrens' Hospital and Bowring and Lady Curzon Hospital, Bangalore during the period November 2009 to May 2011. Enterovirus in fecal samples of 122 children with acute gastroenteritis was detected by its cytopathic effects in rhabdomyosarcoma and / or HeLa cells, followed by reverse transcription (RT)-PCR and sequence analysis of the VP1 gene. All the enterovirus positive samples were tested for wild and OPV poliovirus strains. As rotavirus is the most common cause of viral diarrhea in India, the stool samples were also analyzed for rotavirus using polyacrylamide gel electrophoresis. Results: Out of the 122 samples analyzed, 14 (11.5%) were confirmed enterovirus positive. The enterovirus detection was maximal in the months of June to August (monsoon), with a rate of 30.8%. Rotaviral detection rate was 22% and with maximal prevalence in winter months of December to February. Enterovirus detection rate was highest in the age group of less than six months, with a rate of 50%. The primary symptom was watery diarrhea with mean duration of four days and frequency of 7 per day. Fever and vomiting were present in 50% of the cases. Moderate dehydration was observed in 57.1% of the cases. A significant association was observed between enterovirus associated diarrhea and absence of breastfeeding (p = 0.016), contact with individuals having diarrhea (p = 0.009), and advanced protein energy malnutrition (p = 0.045). Conclusions: Enterovirus associated diarrhea has a significant prevalence among children less than five years and is common in the monsoon season.
Bryce J, Pinto CB, Shibuya K, Black RE. The WHO Child Health Epidemiology Reference Group. WHO estimates of the causes of death in children. The Lancet. 2005; 366:1827-1902
Finkbeiner SR, Allred AF, Tarr PI, Klein EJ, Kirkwood CD, and Wang D. Metagenomic Analysis of Human Diarrhoea: Viral Detection and Discovery. PLoS Pathogens. 2008;4: e1000011
Bass DM. Rotaviruses, Caliciviruses, and Astroviruses. In: Kleigman RM, Jenson HB, Behrman RE, Stanton BF, editors. Nelson textbook of pediatrics. 19th ed. Philadelphia: Elsevier; 2011.p.1134-37.
Patil PR, Chidambar SD and Gopalkrishna V. Molecular detection of enteroviruses among children hospitalised with acute gastroenteritis from Pune, Maharashtra. Indian Journal of Virology. 2009; 20: 30, 31.
Phan TG, Nguyen TA, Shimizu H, Yagyu F, Okitsu S, Müller WEG, and Ushijima H. Identification of enteroviral infection among infants and children admitted to hospital with acute gastroentritis in Ho Chi Minh City, Vietnam. Journal of Medical Virology. 2005; 77:257–264.
Nyangao JW, Kingori P, and Okoth FA. Detection and identification of echovirus 7 from a child with gastro-enteritis. East African Medical Journal. 2006 Dec; 83: 666–669.
Verboon-Maciolek MA, Krediet TG, Loon AM, Kaan J, Galama JMD, Gerards LJ, et al. Epidemiological survey of neonatal non-polio enterovirus infection in the Netherlands. Journal of Medical Virology.2001; 66:241–245.
Syriopoulou VP, Chatzicou V, Pavlopoulou I, Theodoridou M, Hadjichristodoulou C, Pirounaki M, et al. Clinical and epidemiological aspects of an enterovirus outbreak in a neonatal unit. Journal of Hospital Infection. 2002; 51: 275–280.
Rao DC, Babu AM, Raghavendra A, Dhananjaya D, Kumar S , Maiya PP. Non-polio enteroviruses and their association with acute diarrhea in children in India. Infect Genet Evol. 2013; 17: 153–161.
Rai BS, Mansor WH, Vasantha T, Norizah L, Chua KB. An outbreak of echovirus 11 amongst neonates in a confinement home in Penang, Malaysia. Med J Malaysia. 2007; 62:223-6.
Nyangao JW, Kingori P, Okoth FA. Detection and identification of echovirus 7 from a child with gastro-enteritis. East Afr Med J. 2006; 83:666-9.
Oberste MS, Maher K, Kilpatrick DR, Pallansch MA. Molecular evolution of the human enteroviruses: correlation of serotype with VP1 sequence and application to picorna virus classification. J. Virol. 1999; 73: 1941–8.
Ravaoarinoro M, Rafalimanana C, Coulanges P. Viral etiology of diarrheal diseases in Madagascan children. Arch Inst Pasteur Madagascar. 1986; 52:123-30.
Morag A, Abed Y, Schoub BD, Lifshitz A, Zakay-Rones Z. Enteric viral infections in Gaza children—incidence and associated factors and phenomena. Isr J Med Sc. 1995; 31:49-53.
Rimoldi SG, Stefani F, Pagani C, Chenal LL, Zanchetta N, Di Bartolo I, et al. Epidemiological and clinical characteristics of pediatric gastroenteritis associated with new viral agents. Arch Virology. 2011; 156:1583-9.
Chaimongkol N, Khamrin P, Suantai B, Saikhreang W, Thongprachum A, Malasao R, et al. A wide variety of diarrhea viruses circulating in pediatric patients in Thailand. Clin Lab. 2012; 58:117-23.
Harada S, Okada M, Yahiro S, Nishimura K, Matsuo S, Miyasaka J, et al. Surveillance of pathogens in outpatients with gastroenteritis and characterization of sapovirus strains between 2002 and 2007 in Kumamoto Prefecture, Japan. J Med Virology. 2009; 81:1117-27.
Silva P A, Stark K, Mockenhaupt FP, Reither K, Weitzel T, Ignatius R, et al. Molecular characterization of enteric viral agents from children in northern region of Ghana. Journal of Medical Virology. 2008; 80:1790–1798
Agboatwalla M, Isomra S, Akram DS, Isihara Y, Sakae K, Yamashita T, et al. Enteric viral infections in pre-school children in Karachi, Pakistan. Indian Journal of Pediatrics.1995; 62:345–351.
Sadeharju K, Knip M, Virtanen SM, Savilahti E, Tauriainen S, Koskela P, et al. Maternal antibodies in breast milk protect the child from enterovirus infections. Pediatrics. 2007; 119:941