By Kimberly E Clash, RN, BSN

The Organism

• Rotavirus, an RNA virus, is a member of the family Reoviridae and includes seven distinct antigenic groups (A-G). Group A viruses are the major cause of rotavirus diarrhea in the U.S. and groups B and C can cause gastroenteritis in adults (1).
• In developing countries, rotavirus accounts for a significant number of gastroenteritis-associated deaths.
• In the United States, rotavirus accounts for a 3.5 million cases of diarhea, 50,000 hospitalizations, and 20 deaths in children younger than 5 years of age.
• Rotavirus is an important cause of gastroenteritis in infants and young children in both developed and developing countries (4). promote growth of Legionella (9).

Epidemiology

Risk of Infection

• Almost all children are infected with rotavirus within the first 3 years of life.owing to the difficulties with recovering the organism (7).
• The maximum incidence of rotavirus gastroenteritis is between 6 and 24 months of age, however clinical disease can also occur at younger ages.
• Onset of maximum susceptibility correlates with the decline of maternally acquired immune factors, which typically disappear around 5 months.
• Twenty five percent of disease resulting in hospitalization occurs in children older than 2 years of age.
• Susceptibility to infection with rotavirus continues throughout life with the most severe disease associated with the infant's first infection.
• Rotavirus infection in the adult population has been reported in military populations, hospital workers and as a cause of travelers' diarrhea.
• Adult rotavirus infection occurs most commonly in the parents of infected infants, infecting approximately 50% of parents. One third of these adult infections are asymptomatic.
• Reinfection does occur in both children and adults (4).

Distribution

• Regional urban outbreaks typically occur in North America beginning in the south and progressing to the north and east. These outbreaks last 4-5 months and occur primarily in the winter months leaving the summer months virtually free of rotavirus disease.
• In the tropics, rotavirus outbreaks occur in several seasonal peaks or throughout the year (4).

Clinical Manisfestations

• Infants and young children present with fever, vomiting, diarrhea and occasionally dehydration.
• In children admitted to the hospital with rotavirus infection, fever and vomiting persists for 2-3 days, diarrhea for 4-5 days and dehydration is commonly isotonic. · Diarrhea is watery without blood or mucous.
• Diarrhea is watery without blood or mucous.
• Although coryza and cough may precede GI symptoms, replication of rotavirus in the upper respiratory tract is not important in the spread of the virus (4).
• Neurologic symptoms may occur in severe cases as a result of electrolyte imbalance or direct viral infection of the central nervous system (1).
• Rotavirus has also been associated with aseptic meningitis, necrotizing enterocolitis, acute myositis, hepatic abscess, pneumonia, Kawasaki disease, SIDS and Crohn's disease (4).
• Rotavirus induced gastroenteritis in children with immunodeficiency may cause persistent infection lasting weeks or months (1,3).

• Diagnosis of rotavirus infection requires identification of the etiologic agent.
• Routine diagnosis is based on the identification of rotavirus in feces or suspensions of rectal swabs.
• Detection of rotavirus is routinely done by enzyme linked immunosorbent assay (ELISA) test for rotavirus specific antigen. ELISA can be used to detect antigen late in the course of illness (1,3).
• For rapid diagnosis, latex agglutination kits may be used.
• Polyacrylamide gel electrophoresis with silver stain may also be used to diagnose rotavirus infection without false positives and can be used to differentiate non-group A from group A rotavirus (4).

Treatment

• Therapy for rotavirus-induced diarrhea involves replacement of fluids and electrolytes lost during infection.
• The Committee on Nutrition of the American Academy of Pediatrics recommends: (1) feeding (breast milk or diluted formula in infants and lactose free carbohydrate rich foods in older children) within 24 hours after onset of illness and (2) the use of oral rehydration therapy in children with mild or moderate dehydration.
• Fruit juices and soft drinks are not recommended due to their high glucose content, low sodium content and high osmolarity.
• Antibiotics, antisecretory drugs, antimotility drugs, absorbents and antiemetics do not ameliorate acute infection, prevent reinfection or reduce fluid losses during rotavirus induced gastroenteritis, and therefore do not play a role in treatment (4).
• Children with immunodeficiency disorders may be treated with rotavirus-specific immunoglobolin preparation. Administer orally to decrease shedding and ameliorate disease (4).

Prevention

Infection Control

• The mode of transmission of rotavirus infection is primarily fecal-oral.
• Infected infants shed virus in feces in high concentration at disease onset and for 4-7 days after onset. Immunocompromised patients can excrete virus for 30 days or more (3).
• The handling of infected infants' diapers and the hygienic habits of toddlers allows for the spread of the virus (4)
• Virus survives on hard surfaces, hands, and in contaminated water for several days. .
• It is relatively resistant to common disinfectants, but is inactivated by chlorine.
• In outbreaks, search for inanimate objects that may be a vector.
• Strict adherence to handwashing measures and cohorting infected infants is recommended for the duration of the illness (1).
• Currently at the Johns Hopkins Hospital, patients with rotavirus are isolated on Contact Precautions.

The Vaccination

American Academy of Pediatrics Committee on Infectious Diseases issued a statement in 1999 regarding the licensed tetravalent rotavirus vaccine (RRV-TV), Rotashield. It states that the CDC has received reports of 23 cases of intussusception after receipt of doses 1,2 or 3 of RRV-TV. It was recommended that clinicians suspend administration of the rotavirus vaccine to unimmunized and partially immunized children (2).

References

1. American Academy of Pediatrics. (1997). Rotavirus. In Red book: Report of the committee on infectious diseases. (24th ed., pp.454 - 456). Elk Grove Village, IL:Author.
2. American Academy of Pediatrics Committee on Infectious Diseases. (1999). Possible association of intussusception with rotavirus vaccination. Pediatrics, 104, 575.
3. Chin, J. (Ed.). (2000). Control of Communicable Disease Manual. Wash. DC: American Public Health Association.
4. Offit, P. A. & Clark, M. F. (2000). In G. L. Mandell, J. E. Bennett, & R. Dolin (Eds)., Principles and practice of infectious diseases. (5th ed., pp.1696 -1703). Philadelphia, PA: Churchill Livingstone.

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