Rotavirus & Gastroenteritis: Thousands of Children Still Die From This Virus. Here’s All You Need to Know

History

The history of the discovery of rotavirus began in 1943 with Dr. Jacob Light and Dr. Horace Hodes. They were the first scientists to identify an infectious agent causing severe diarrhea in both children and livestock. Decades later, this pathogen was definitely determined to be rotavirus [3]. 

A second major step in the study of rotavirus was made in 1973 when Dr. Ruth Bishop, a noted Australian virologist, and her colleagues collected biopsies of intestinal tissue and fecal samples from children suffering from severe diarrhea [2,3]. They discovered that the causative agent was  rotavirus. 

Interestingly, one year later, an English virologist and physician named Dr. Thomas Henry Flewett named the pathogen studied by the abovementioned scientists “rotavirus.” He came up with this name after viewing the virus through an electron microscope and noticing that this tiny structure resembled a wheel. Since the Latin word for wheel is “rota”, the term “rotavirus” seemed apt. In fact, the International Committee on Taxonomy of Viruses officially recognized the name four years later.

In 1980, it was discovered that various distinct variants of the virus existed. A year later, scientists grew rotavirus isolates from humans using cell cultures derived from the kidneys of monkeys. This development was a major milestone that helped lead to the invention of effective vaccines against this viral infection during the mid-1980s.

In 1998, the first rotavirus vaccine was licensed for general use in the United States. Clinical trials conducted in the US, Finland, and Venezuela showed that the vaccine had no adverse side effects and was 80-100% effective in protecting against the infection. However, it was discontinued a year later when it was discovered that one in 12,000 infants who received the vaccine experienced obstructions in their bowels. This was a major setback, but future developments led to more promising treatments.

Two new vaccines were introduced in 2006 and were found to be safe and effective in children. In 2009, the World Health Organization (WHO) included these rotavirus vaccines in all national immunization programs. As a result, many countries, including the US, have reported a significant reduction in rotavirus-related deaths and hospitalizations.

Currently, rotavirus vaccines are licensed for general use in over 100 countries. Non-profit international health organizations, including WHO, PATH, and the CDC, have partnered with many governments throughout the world, as well as various research institutions, to make rotavirus vaccines accessible and affordable to people living in low- and middle-income countries [3].

Epidemiology

Rotavirus infections have been reported worldwide. They are more severe in children under five years of age, the elderly, and immunocompromised individuals [3]. 

Disease-related deaths are more common in low-income countries compared to developed nations. The top factors leading to rotavirus-related deaths in these countries are as follows:

• Malnutrition
• Lack of proper healthcare facilities
• Inadequate vaccination coverage 

Incidence

In parts of the world with temperate climates, incidence of rotavirus is highest during the winter. However, in tropical regions, rotavirus infections occur throughout the year [2].

Types of Rotavirus

There are eight different species of rotaviruses: A, B, C, D, E, F, G, and H.

• Species A, B, and C mainly cause infections in humans. 
• Species D, F, and G primarily infect birds. 
• Species E and H cause infections in pigs. 
• Species A, B, C, D, and E can cause illness in a number of different animal species.

Over 90% of rotavirus-inflicted gastroenteritis in humans worldwide is caused by rotavirus A (RVA) [3]. It is responsible for 200,000 deaths and several million hospitalizations across the world every year [13].

Rotavirus outbreaks

In 1977, Brazil witnessed a massive rotavirus outbreak. Four years later, contamination of drinking water in the US state of Colorado led to an outbreak of rotavirus-inflicted gastroenteritis [3]. 

In 2003, about 114 million cases of rotavirus infections were reported across the globe. The affected population consisted mostly of children under the age of five. It resulted in 24 million visits to physicians and 2.3 million hospitalizations worldwide [4]. 

In 2005, Nicaragua, a country in Central America, witnessed a massive rotavirus-inflicted viral gastroenteritis outbreak. Around 47,470 visits to doctors were made between February and April of that year. Nicaragua’s health ministry reported 52 deaths. All were children under two years of age. Leon, Granada, Madriz, and Neuva Segovia departments were the most affected. The case-fatality rates in these areas of the country were 19.2%, 24%, 24.1%, and 18.9%, respectively [5].  

The US is among the many countries that have seen a remarkable reduction in the number of rotavirus-related deaths in children. This is mainly due to widespread vaccination. In the pre-vaccination era, around 2.7 million rotavirus infections were reported across the country annually. These led to over 400,000 visits to physicians, about 55,000 – 70,000 hospitalizations, and 20 – 60 deaths of children under five each year. 

After widespread vaccination programs were initiated in 2006, the number of annual visits to doctors’ offices due to rotavirus dropped from approximately 400,000 to about 280,000, and the number of hospitalizations from this same illness fell to around 45,000 [1]. 

Unfortunately, deaths from rotavirus continue to occur in many parts of the world despite ongoing immunization efforts. According to WHO, about 453,000 rotavirus-related deaths occurred globally in 2008 alone. This accounted for 5% of all childhood deaths worldwide [6]. In 2013, the rotavirus claimed the lives of approximately 215,000 children under the age of five worldwide. Almost 90% of these deaths were reported from low- and middle-income countries [3]. 

About 87,000 people in Europe are hospitalized annually due to acute gastroenteritis caused by rotavirus. Incidence is highest among children between six and 23 months of age. Today, many European countries are part of the universal mass vaccination (UMV) program. This has made a significant impact on reducing the number of hospitalizations. 

Belgium, Finland, Germany, England, and Norway have, respectively, reported 87%; 92%; 27–70%; 83–94%; and 73% reductions in the number of hospitalizations from rotavirus-related viral infections [7].

How is it spread?

Rotavirus is extremely contagious and can spread from person to person. These are the different ways humans can become infected:

• People can contract a rotavirus infection by eating contaminated food. Infected individuals can contaminate the food if their hands have even minute amounts of feces or vomit particles on them.
• Surfaces can become contaminated when an infected person touches them with their bare hands.
• While passing stool, infected individuals can splatter their feces onto the surface of the toilet and contaminate the environment [8].

Biology of the disease

The rotavirus enters the human body through the mouth. Once the viral particles reach the digestive tract, they replicate in cells that line the inner surface of the small and large intestines. 

During this process, the virus damages enterocytes and intestinal villi (finger-like projections of cells lining the small intestine). Healthy villi are critical for the body to absorb nutrients. This means that even if a person eats healthy foods, they may still not be able to absorb vital nutrients. In these cases, people can experience severe nutritional disorders, including malabsorption and osmotic diarrhea [2].

Symptoms

It takes 1-3 days for symptoms to appear after exposure to the rotavirus virus. 

Symptoms caused by the rotavirus infection appear similar to other gastrointestinal diseases but are usually more severe. It may take 5-7 days following the onset of the symptoms for the illness to subside. 

Common rotavirus symptoms include: 

• Fever
• Vomiting
• Watery diarrhea
• Malaise

Other less common symptoms include:

• Convulsions
• Encephalitis
• Encephalopathy [1, 2].

Watery diarrhea causes dehydration, resulting in decreased frequency of urination, sleeplessness, dizziness while standing, and dry mouth or throat [9].

Diagnosis

Diagnosing a rotavirus infection is challenging because symptoms are very similar to a number of other diseases, including those caused by  noroviruses, astroviruses, and salmonella.

In order to make a definitive diagnosis, stool samples are first collected and then sent to a laboratory for testing. Standard diagnostic methods used in detecting rotavirus infection include the following:

• Enzyme-linked immunosorbent assay (ELISA) or immunochromatography: More effective during the first week after the onset of the symptoms.
• Reverse transcription PCR (RT-PCR)-based assays: This method is usually more sensitive and helps determine differences in the virus’s genetic makeup [4].

Treatment

There is no treatment or cure for rotavirus infections. Since rotavirus is not caused by bacteria, antibiotics are of no use. Treatment usually involves supportive care directed at relief from pain and discomfort. It also often includes the following:

• Fluid therapy (mainly oral) to alleviate dehydration caused by diarrhea.
• The administration of intravenous fluids (saline and sodium lactate solutions). In such cases, patients must be hospitalized to monitor electrolyte levels carefully.
• Taking probiotics such as lactobacillus spp. These are administered to reduce the duration of diarrhea. Probiotics can shorten the course of diarrhea by 1-2 days. 
• To control the severity and volume of diarrhea in adults, drugs like codeine, loperamide, and diphenoxylate may work; however,  they are rarely used in children.
• Bismuth salicylate can provide some relief from discomfort. But, it is only administered in the absence of infections caused by other pathogens [2,10,11, 12].

Prevention

Vaccines are the best available resources to protect against rotavirus infection. They are safe, effective, and administered orally during the first year of a newborn’s life. 

According to the CDC, rotavirus vaccines provide 85% to 98% protection against severe illness. 

The following vaccines are approved for general use in infants:

• RotaTeq – RotaTeq was first licensed in 2006. It is given in three doses administered at two months, four months, and six months. 
• Rotarix – Rotarix was first licensed in 2008. It is administered in two doses at two months and four months [12].

Other preventive measures include:

• Avoiding close contact with children infected or suspected to be infected with rotavirus.
• Wearing personal protective equipment, including gloves and gowns, while caring for infected individuals.
• Washing hands regularly, especially before eating or handling food. This is because rotavirus virions can survive on the fingers of humans for about one hour. Also, washing hands after touching surfaces that could be contaminated with the virus is also very helpful.
• Disinfecting surfaces that could be contaminated with commercially available disinfectants [10].

In conclusion, rotavirus is a highly infectious and potentially deadly virus that mainly infects young children. There is no treatment, and differential diagnosis is difficult. While this may seem daunting, there is good news: vaccination is an effective way to prevent infection and the spread of illness. 

Practicing good hygiene, such as washing hands regularly and avoiding contact with infected individuals, can help prevent the spread of the rotavirus. Countries experiencing rotavirus-related deaths should drive national immunization programs to improve vaccination rates. With proper education, preventive measures, and robust infectious disease research, we can work together to reduce the impact of the rotavirus virus worldwide.

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