Basics
Description
Rotavirus is a leading cause of gastroenteritis in the United States and worldwide. Characterized by frequent watery stools, illness ranges from mild diarrhea to disease complicated by severe dehydration, especially in young children.
Epidemiology
- Rotavirus is a major cause of diarrheal disease and accounts for 5% of all deaths in children <5 years of age worldwide.
- The peak age for infection is between 6 and 24 months of age. Nearly all children acquire the virus by 5 years of age.
- In temperate climates, rotavirus activity peaks during the cold weather months but can appear year round in warmer climates.
- Transmission occurs primarily by the fecal " oral route.
- Rotavirus is highly contagious. This is due to several factors.
- The virus has a very low inoculum of infection, requiring as few as 10 infectious particles to cause disease.
- A high density of virus is shed into the stool during acute illness and for 1 " 3 days before and after diarrhea.
- There is prolonged survival of the virus on a variety of environmental surfaces.
- The incubation period is 1 " 3 days.
- Prior to the rotavirus vaccine, U.S. children <5 years of age with diarrhea had a hospitalization rate of 52/10,000 person-years and an ED visit rate of 185/10,000 person-years.
- After the rotavirus vaccine was introduced in 2006, the hospitalization rate for all children <5 years with diarrhea fell by nearly 50% and ED visits by 25%.
Risk Factors
- Young infants, especially preterm infants, are at higher risk for severe dehydration and gastrointestinal complications.
- Immunocompromised patients, particularly with primary immunodeficiencies and hematopoietic stem cell transplantation are at higher risk for complications and prolonged shedding.
General Prevention
- Proper hand hygiene and cleaning of contaminated surfaces is essential to reducing person-to-person transmission.
- Contact precautions for hospitalized patients
- Two live oral vaccines are licensed in the US:
- Live human/bovine reassortant pentavalent rotavirus (RV5). Given as a 3-dose series.
- Live human attenuated monovalent rotavirus (RV1). Given as a 2-dose series.
Pathophysiology
- Rotavirus infects and replicates within the enterocytes of the small bowel. Several factors appear to contribute to secretory diarrhea.
- The nonstructural protein (NSP4) acts as an enterotoxin that triggers secretory diarrhea by increasing Cl ’ secretion and decreasing Na+ absorption.
- Malabsorption develops due to disruption of microvilli and decreased surface transport of digestive enzymes.
- NSP4 appears to activate the enteric nervous system, which activates a secretory state that further contributes to intestinal fluid loss.
Etiology
- Rotavirus is an 11-segment double-stranded RNA virus with 7 different antigenic groups (A " G).
- Types A, B, and C are responsible for most human infections, with group A being the most common.
- Group A rotavirus is further divided into multiple serotypes based on 2 outer capsid viral proteins: VP7 (G) and VP4 (P).
Diagnosis
History
- Stools are watery and often foul-smelling.
- Gross blood or mucus is usually absent " their presence more often suggests a bacterial pathogen.
- Diarrhea usually lasts 3 " 8 days.
- Stool frequency can range from several to 20 episodes per day.
- Vomiting accompanies diarrhea 85% of the time. Vomiting often precedes diarrhea and resolves in 1 " 2 days.
- Fever can exceed 102 °F in 1/3 of patients.
- Two thirds of patients present with diarrhea, vomiting, and fever.
- Family members often have a history of current or recent diarrhea.
Physical Exam
Relevant physical findings are targeted to assess for potential dehydration.
Diagnostic Tests & Interpretation
Lab
- Serum electrolytes, BUN, and creatinine are important in evaluating for dehydration and electrolyte abnormalities secondary to diarrhea.
- Rapid tests for rotavirus
- By EIA or latex agglutination
- Have an overall sensitivity of 80% and specificity of 99%
- Sensitivity is highest in the first 4 days of illness.
- Rapid PCR testing is becoming increasingly available for rotavirus, including multiplex assays that incorporate other common agents of viral gastroenteritis.
- Fecal leukocyte and stool guaiac testing is not helpful.
- Two thirds of hospitalized children have mild elevations in their transaminases.
Differential Diagnosis
- Viral pathogens occur in 80 " 90% of patients with secretory diarrhea. Besides rotavirus, common gastrointestinal viruses include the following:
- Norovirus
- Sapovirus
- Astrovirus
- Enteric adenovirus
- Bacterial infections may present with secretory diarrhea.
- Salmonella
- Shigella
- Campylobacter
- Aeromonas
- Clostridium difficile
- Yersinia
- Parasitic infections:
- Giardia
- Cryptosporidium
- Cyclospora
- Isospora
Treatment
Medication
- Antimotility agents are generally avoided for all forms of infectious diarrhea in children.
- Several studies suggest that supplementation with a specific probiotic strain, Lactobacillus rhamnosus GG, during acute rotavirus gastroenteritis might decrease the duration of diarrhea (mean duration decrease: approximately 1 day).
Inpatient Considerations
Initial Stabilization
- Provide appropriate intravenous, nasogastric, or oral fluids for volume replacement and correction of electrolyte abnormalities due to diarrhea.
- Monitor fluid balance and serum electrolytes.
- Place patients in contact precautions.
Ongoing Care
Complications
- Hypernatremia and metabolic acidosis occur more often with rotavirus gastroenteritis than other forms of viral gastroenteritis and may become severe enough to require intensive care management.
- Gram-negative sepsis can occur secondary to mucosal injury.
- Rotavirus gastroenteritis has been associated with necrotizing enterocolitis in preterm infants.
- Diarrhea may be more severe and protracted in immunocompromised hosts.
Additional Reading
- Bernstein DI. Rotavirus overview. Pediatr Infect Dis J. 2009;28(3)(Suppl):S50 " S53. [View Abstract]
- Cortes JE, Curns AT, Tate JE, et al. Rotavirus vaccine and health care utilization for diarrhea in U.S. children. N Engl J Med. 2011;365(12):1108 " 1117. [View Abstract]
- Cox E, Christenson JC. Rotavirus. Pediatr Rev. 2012;33(10):439 " 445; quiz 446 " 447. [View Abstract]
- Curns AT, Steiner CA, Barrett M, et al. Reduction in acute gastroenteritis hospitalizations among US children after introduction of rotavirus vaccine: analysis of hospital discharge data from 18 US states. J Infect Dis. 2010;201(11):1617 " 1624. [View Abstract]
- Dennehy PH. Treatment and prevention of rotavirus infection in children. Curr Infect Dis Rep. 2013;15(3):242 " 250. [View Abstract]
- Kaiser P, Borte M, Zimmer KP, et al. Complications in hospitalized children with acute gastroenteritis caused by rotavirus: a retrospective analysis. Eur J Pediatr. 2012;171(2):337 " 345. [View Abstract]
- Madhi SA, Cunliffe NA, Steele D, et al. Effect of human rotavirus vaccine on severe diarrhea in African infants. N Engl J Med. 2010;362(4):289 " 298. [View Abstract]
- Tate JE, Burton AH, Boschi-Pinto C, et al. 2008 estimate of worldwide rotavirus-associated mortality in children younger than 5 years before the introduction of universal rotavirus vaccination programmes: a systematic review and meta-analysis. Lancet Infect Dis. 2012;12(2):136 " 141. [View Abstract]
Codes
ICD09
- 008.61 Enteritis due to rotavirus
ICD10
- A08.0 Rotaviral enteritis
SNOMED
- 186150001 Enteritis due to rotavirus (disorder)
- 359662008 rotavirus infection of children (disorder)
FAQ
- Q: How long are children contagious following rotavirus infections?
- A: In most children, rotavirus shedding ceases within 7 days of the diarrhea resolving. However, asymptomatic shedding can persist in some children for up to several weeks " and in some cases longer. Young infants with severe diarrhea and immunocompromised patients are more likely to have persistent asymptomatic rotavirus shedding and may pose a risk for spread in the day care and hospital setting.
- Q: Is there a risk for intussusception with rotavirus vaccine?
- A: Postlicensure data for the RV5 and RV1 vaccines do point to a slightly higher risk for intussusception following administration of the first two doses of rotavirus vaccine. This infrequent complication; however, is far outweighed by the vaccine 's substantial benefits in reducing hospitalization and death, and its worldwide use is strongly recommended.