Rotavirus: The Virus on Wheels

Alexander Motylev, RPh, PhD
Published Online: Tuesday, May 1, 2007

Rotavirus is a seasonal virus that should not be underestimated. It causes acute gastroenteritis (irritated or inflamed stomach or intestinal surface) in children 5 years of age or younger, leading to severe cases of dehydration in children 3 to 35 months of age.1-8

Viral Nature

In 1973, Australian scientists led by Ruth F. Bishop looked at a sample of duodenal mucosa taken from children with acute nonbacterial gastroenteritis. The investigators observed virus particles with a diameter of ~70 nm, which were later named rotavirus.9 Rotavirus is an RNA virus. It belongs to the Reoviridae family and got its name from its wheel appearance (Latin rota = wheel).

Rotavirus has 7 antigenic groups: A, B, C, D, E, F, and G. The Group A virus has multiple strains, with 3 protein layers and a diameter of 70 to 75 nm. It causes rotavirus diarrhea in children in the United States. Groups B and C affect adults, causing gastroenteritis.10-12

Clinical Presentation

In the United States, rotavirus appears at the end of the fall/beginning of the winter (November-December) in the southwestern part of the country. Closer to the middle of spring (April-May), it appears in the northeastern regions of the country.

Children show symptoms in ~2 days, once they are infected with rotavirus.The symptoms are fever, nausea, vomiting, stomach and abdominal pain, watery diarrhea, and (most dangerous) dehydration. Symptoms can last for 3 to 9 days.13,14

Pathology

Rotavirus spreads between people by means of the fecal-oral route of transmission. Once it is in the body, the virus starts to infect the cells constituting the small intestinal villi. Normally, these cells take part in processes occurring in the intestine, such as the absorption of fluids and electrolytes and the breakup of carbohydrates. Infection of these cells primarily causes malfunctions in the decomposition process of carbohydrates and fluid loss from the intestine.

Bishop found unusually low levels of lactase, maltase, and sucrase enzymes.9 These enzymes are made in the small intestine. Lactase, a glycoside hydrolase, has a role in the hydrolysis of the disaccharide lactose. A deficiency of this enzyme leads to lactose intolerance. Maltase plays a role in the hydrolysis of maltose. Sucrase is an enzyme that carries the hydrolysis of sucrose to fructose and glucose. The diminished secretion of sucrase leads to the condition known as sucrose intolerance. This condition is described as excessive gas production and often diarrhea. Furthermore, rotavirus initiates physiologic changes in the villus epithelium, leading to a decrease in absorptive properties and further worsening of the condition.15

Risk Factors

Experimental data have shown 2 main risk factors for rotavirus gastroenteritis. They are (1) contact with persons having gastroenteritis and (2) poor food-handling hygiene in the household.16 Young age (6 months -2 years) is another risk factor. Furthermore, premature infants and children with weakened immune systems are the most defenseless groups.11

Diagnostic Tools

Every child infected with rotavirus excretes 109 to 1010 viral particles for each gram of feces. Patients' stool samples are chosen for analysis. The samples are tested by enzymelinked immunosorbent assay and enzyme immunoassay. To generate results, these assays require at least 104 to 106 viral particles. They both are Group Aspecific. In the case of a positive result, IgM and IgA rotavirus is found to be present in the infected patient's stool.17-22

Prophylaxis

RotaTeq (Merck) rotavirus vaccine is a live human and bovine pentavalent vaccine. This vaccine consists of G1, G2, G3, G4, and P1 proteins aiming at rotavirus serotypes, which are responsible for >90% of cases of nonbacterial, rotavirusrelated gastroenteritis in the United States.23 RotaTeq is indicated for the prophylaxis of viral gastroenteritis due to rotavirus. This vaccine is given according to the following schedule:

  • 2 mL (entire pouch) orally at 2 months (first dose between 6 and 12 weeks of age)
  • 4 months (second dose between 10 and 22 weeks of age)
  • 6 months (third and last dose between 14 and 32 weeks of age)
  • All 3 doses by the age of 32 weeks (per the American College of International Physicians recommendations)

The most common side effects documented after the administration of this vaccine are diarrhea and vomiting. When RotaTeq vaccine came on the market, the rates of intussusception associated with its usage were similar to the rates with placebo. On February 13, 2007, however, the FDA issued a Public Health Notification informing health care providers about an additional 28 cases of intussusception since the vaccine was marketed.24 Therefore, caution should be exercised while administering RotaTeq to the pediatric population with gastrointestinal disorders.

Prevention

Breast milk helps infants fight rotavirus. Specifically, glycoproteins such as mucin and lactadherin were found in mothers'breast milk and were found to be helpful in the fight against rotavirus. IgA antibodies transmitted with breast milk to the baby give immunity against rotavirus for up to 4 months.25-29

Treatment

The treatment decision is made by the pediatrician. If the physician decides to keep a sick child at home, oral rehydration therapy would be indicated. Pedialyte (Ross) is an oral product with low osmolality. It is used in infants and children to prevent dehydration caused by diarrhea and vomiting. The main constituents of Pedialyte are water and important electrolytes such as sodium, potassium, and chloride. This product replaces water and electrolytes lost while children are vomiting and having diarrhea.

The total daily volume requirement for administered Pedialyte is based on age (excluding age of less than 1 week) and weight.30 If the physician decides that a child should be brought to the hospital's emergency room, then the patient will receive fluid rehydration via the intravenous route.

The Pharmacist's Role

The pharmacist can play a key role in caring for patients infected with rotavirus. The pharmacist should inform parents of the key points in home care for a child infected with rotavirus. Parents always should watch out for basic symptoms of dehydration, which include dry diapers, dry and cool skin, dry mouth and tongue, sunken eyes, and extreme thirst.

Parents should consult the pediatrician as to whether they should still feed their baby with formula. Furthermore, parents should be very choosy about the liquids they give to a baby who has rotavirus. They should avoid giving hyperosmolar drinks, such as sports drinks, commercial soft drinks, and commercial soup; use of these products may lead to hypernatremia. Likewise, an excessive free-water intake may lead the baby to the hyponatremic state. Antiemetic and antidiarrheal medications generally should be avoided unless recommended by the pediatrician.

Important information to give parents is that they should protect other babies, if any, in the family by following a good hand-washing technique, or by avoiding playing with sick children. Parents should be ready to inform the physician on the daily progress on the condition of a sick baby. See the sample log in the Table to help parents in collecting information for their pediatrician.

Likewise, in the hospital, pharmacists should follow and inform caregivers about any changes in the hemodynamic status of their patients.

Dr. Motylev is a pharmacy manager in the hospital setting.

References

1. Rotavirus. Centers for Disease Control and Prevention Web site. Available at: www.cdc.gov/rotavirus. Accessed January 15, 2007.

2. Bernstein DI, Ward RL. Rotaviruses. In: Feigin RD, Cherry JD, eds. Textbook of Pediatric Infectious Diseases. 5th ed. Vol 2. Philadelphia, Pa: Saunders; 2004;4:2110-2133.

3. Centers for Disease Control and Prevention. Rotavirus Vaccine for the Prevention of Rotavirus Gastroenteritis Among Children: Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Morb Mortal Wkly Rep. 1999;48(RR-2):1-24.

4. Glass RI, Bresee JS, Parashar U, et al. Rotavirus vaccines: past, present, and future. Archives de P?diatrie. 2005;12:844-847.

5. Cornell SL. Confronting the consequences of rotavirus: diarrhea and dehydration. Adv Nurse Pract. 1997;5(4):41-44.

6. Velazquez FR, Matson DO, Calva JJ, et al. Rotavirus infections in infants as protection against subsequent infections. N Engl J Med. 1996;335:1022-1028.

7. Rodriguez WJ, Kim HW, Brandt CD, et al. Longitudinal study of rotavirus infection and gastroenteritis in families served by a pediatric medical practice: clinical and epidemiologic observations. Pediatr Infect Dis J. 1987;6:170-176.

8. Gurwith M, Wenman W, Gurwith D, Brunton J, Feltham S, Greenberg H. Diarrhea among infants and young children in Canada: a longitudinal study in three northern communities. J Infect Dis. 1983;147:685-692.

9. Bishop RF, Davidson GP, Holmes IH, Ruck BJ. Virus particles in epithelial cells of duodenal mucosa from children with acute non-bacterial gastroenteritis. Lancet. 1973;1:1281-1283.

10. American Academy of Pediatrics. Rotavirus. In: Red Book: Report of the Committee on Infectious Diseases. 24th ed. Elk Grove Village, IL: American Academy of Pediatrics; 1997:454-456.

11. Rotavirus Facts. Available at: www.rotavirus.org/rotavirus-facts.htm. Accessed January 9, 2007.

12. Glass RI, Parashar UD. The Promise of New Rotavirus Vaccines. N Engl J Med. 2006;354(1):75-77.

13. Matson DO. Rotaviruses. In: Long SS, Pickering LK, Prober CG, eds. Principles and Practice of Pediatric Infectious Diseases. 2nd ed. Philadelphia, Pa: Elsevier- Health Sciences Division; 2002:1104-1110.

14. Blacklow N. Viral gastroenteritis. In: Gorbach, Bartlett, Blacklow, eds. Infectious Diseases. 3rd ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 2004:677-681.

15. Anderson EJ, Weber SG. Rotavirus infection in adults. Lancet Infect Dis. 2004;4(2):91-99.

16. de Wit MA, Koopmans MP, van Duynhoven YT. Risk factors for norovirus, Sapporo-like virus, and group A rotavirus gastroenteritis. Emerg Infect Dis. 2003;9(12):1563-1570.

17. Yolken RH, Wilde J. Assays for detecting human rotavirus. In: Kapikian AZ, ed. Viral Infections of the Gastrointestinal Tract. 2nd ed. New York: M Dekker, 1994:251-278.

18. Wilde J, Yolken RH, Willoughby R, Eiden J. Improved detection of rotavirus shedding by polymerase chain reaction. Lancet. 1991;337:323-326.

19. Desselberger U. Rotavirus infections: guidelines for treatment and prevention. Drugs. 1999;58:447-452.

20. Rotaviruses of man and animals. Lancet. 1975;1:257-258.

21. Hardy DB. Epidemiology of rotaviral infection in adults. Rev Infect Dis. 1987;9:461-469.

22. Rao GG. Control of outbreaks of viral diarrhea in hospitals?a practical approach. J Hosp Infect. 1995;30:1-6.

23. Heaton PM, Goveia MG, Miller JM, Offit P, Clark HF. Development of a pentavalent rotavirus vaccine against prevalent serotypes of rotavirus gastroenteritis. J Infect Dis. 2005;192:S17-21.

24. FDA Public Health Notification: Information on RotaTeq and Intussusception. Available at: www.fda.gov/cber/safety/phnrota021307.htm.

25. Rahman MM, Yamauchi M, Hanada N, Nishikawa K, Morishima T. Local production of rotavirus specific IgA in breast tissue and transfer to neonates. Arch Dis Child. 1987;62(4):401-405.

26. Hjelt K, Grauballe PC, Nielsen OH, Schiotz PO, Krasilnikoff PA. Rotavirus antibodies in the mother and her breast-fed infant. J Pediatr Gastroenterol Nutr. 1985;4:414-420.

27. Yolken RH, Peterson JA, Vonderfecht SL, et al. Human milk mucin inhibits rotavirus replication and prevents experimental gastroenteritis. J Clin Invest. 1992;90(5):1984-1991.

28. Newburg DS, Peterson JA, Ruiz-Palacios GM, et al. Role of human-milk lactadherin in protection against symptomatic rotavirus infection. Lancet. 1998;351:1160-1164.

29. Pickering LK, Morrow AL, Herrera I, et al. Effect of maternal rotavirus immunization on milk and serum antibody titers. J Infect Dis. 1995;172:723-728.

30. Pedialyte. Physicians Desk Reference. 60th ed. Montvale, NJ: Thompson PDR; 2006.




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