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Rotavirus gastroenteritis: the role of the nurse

Sara Richards
RGN BSc(Hons)
Specialist Primary Care Nurse
Berkshire

Rotavirus gastroenteritis (RVG) affects mainly children under five years old and can cause considerable morbidity and, in some cases, mortality if dehydration occurs and is not treated early enough, as well as resulting in a significant economic burden. Because of this, awareness of this disease needs to be heightened and nurses can play a part in helping parents to understand the dangers and the treatment of RVG.

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What is the cause?
The family of rotaviruses (RVs), which can infect both humans and animals, was discovered in the early 1970s and is now thought to be one of the most common causes of diarrhoea in early childhood.(1) It is estimated that 95% of children worldwide develop a rotavirus infection before the age of five.(2) The RVs are so called from the Latin "rota", meaning wheel, because of the circular shape of their particles under electron microscope. They are distinguished by the layered proteins forming the capsid, which can be used to differentiate and classify the strains and which are important to the antigenic response. The RV genus is divided into different serogroups labelled A to E (with two possible additional species F and G). The clinically significant rotaviruses belong to group A. These are further classified into serotypes G and P with G1, G2, G3, G4 and G9 being attributed to causing most cases of RV-induced diarrhoea worldwide. It seems that these viruses are constantly evolving because of their global spread.(3)

What are the symptoms?
The main symptoms are fever, sometimes for one to two days, before diarrhoea, vomiting, abdominal pain and dehydration, all typically self-resolving. More than 20 episodes of diarrhoea or vomiting in 24 hours is not uncommon, with diarrhoea generally lasting from four to eight days.(4) The severity of RV infection ranges from being asymptomatic to causing severe dehydration that can be fatal. In the UK, it is estimated that one in 38 children will be hospitalised for RVG by the age of five and that each year 14 children under five will die.(2,5) Based on symptoms alone a clinician is not able to specifically diagnose RVG because they can be the same for many other types of gastroenteritis, eg, salmonella. A definitive diagnosis requires laboratory tests which are not usually sought unless the child is hospitalised. A child may also have more than one episode due to the different strains in circulation although it seems that 88% of children are protected against severe reinfection after their first rotavirus infection.(3)
At the moment there is no specific treatment except support and rehydration, which is extremely important especially for babies and infants, as even a mild rotavirus infection can become life-threatening without it. Appropriate assessment of dehydration is crucial in order to differentiate those patients who can safely be cared for at home from those who need more intensive therapy. Signs of increasing dehydration include thirst, restless or irritable behaviour, decreased skin turgor, sunken eyes, reduced urine output and sunken fontanelle (in infants). If these occur, intensive rehydration should be promptly initiated.(6)

How are RVs transmitted?
RVG is seasonal in developed countries, occurring mainly in the winter. It is highly contagious and is transmitted via the faecal-oral route, shed in stools and vomit and by respiratory droplets (although there appears to be some controversy about this method of transmission). Only 10 particles are needed for infection, which then proceeds rapidly with symptoms observed within 24-48 hours.(7) Community-acquired outbreaks are common, for example, in childcare facilities through direct contact with individuals and with contaminated toys, nappies, toilets, drinking fountains, telephone receivers or a carer's hands. The viruses are able to survive for a few days on hands and from one to 10 days on dry and nonporous surfaces thus, with presymptomatic shedding of the virus and high virulence, RV transmission is difficult to control.
There is also the risk of nosocomial RV infections for hospitalised patients for the same reasons. RVG is the most common hospital-acquired infection in young children.(8) Isolating the infected patient, reducing contact with noninfected patients and carers and implementing rigorous infection control measures, especially handwashing and the use of alcohol-based hand sanitisers, will reduce the risk of an epidemic. However, RVs are difficult to inactivate as they are resistant to most commonly used soaps and disinfectants although chlorine-based products appear to be fairly effective.(9)

The impact of the rotavirus
The incidence of RVG is similar in industrialised and developing countries, which suggests that differences in environment (eg, hygiene, sanitation and access to clean water) do not affect incidence. Severity, however, seems to be greater in developing countries. This is possibly because access to healthcare may not be as good as in developed countries and people may have further to go to seek help, along with a lack of basic rehydration facilities. Also developing countries are seeing an increase in immunocompromised children who are more severely affected. However, this disease can have a significant impact on families, communities and healthcare facilities and therefore on the economies of all countries worldwide. Accurate country-specific epidemiological data relating to RVG is still not available, mainly due to lack of widespread national surveillance reporting.
A recent publication focusing on the economics of RVG in Europe, has highlighted the different types of costs that result from RVG, including costs for the healthcare system (direct medical costs), for the families of those infected (nonmedical direct costs), and for households and society as a whole (indirect costs).(10)
The direct medical costs in the UK come from visits to the general practitioner, walk-in centre and A&E, advice from NHS Direct, and from hospitalisation (around 18,000 children a year). Because it occurs during the winter months it coincides with the seasonal peak of other childhood viral infections and can be an added burden on the healthcare system.
Nonmedical costs include travel and out-of-pocket expenses for families, extra nappies, washing and rehydration therapy, as well as extra childcare costs and loss of earnings if the RVG spreads to the rest of the family. Adults can also become infected, but their symptoms are usually mild, probably because of the long-lasting immunity given by childhood infection. The physical effects also need to be taken into consideration - the obvious discomfort of the child, disturbed nights and the distress of caring for an ill child. Indirect costs to society come from the overall reduction in labour productivity and the stress of juggling work around home care or hospital visits.

The role of the nurse
RVs remain a serious health concern for young children in the UK. It is very important that nurses educate parents about the symptoms and when help should be sought. Advise parents to keep a child with diarrhoea and vomiting away from other children until 48 hours after the symptoms have stopped to try to prevent onward transmission.
General advice that can be given include:

  • Rehydration with sachets, such as Rehidrat (Searle) or Dioralyte (Sanofi Aventis), plus plenty of water little and often.
  • Do not starve the child, but feed normally if the child wants food/formula or breastmilk.

Good hygiene advice includes:

  • Wash hands well after handling nappies and soiled clothing, using the toilet and cleaning up after diarrhoea or vomiting.
  • Wash hands well before preparing food and drink.
  •  Separate soiled clothing and bed linen and wash on hot wash.
  • Clean and disinfect with bleach products potties, toilet handles, seats and door handles.

Hope for the future
As there is no specific treatment for RVG and the global burden on health services is considerable, prevention by vaccination seems a way forward. The first trials of an RV vaccine were carried out in the early 1980s, but there were problems, as there were with a later vaccine, which was withdrawn in 1999 because of a rare association with intussusception. Since then safety has become a major issue in the development of new vaccines.
The new oral RV vaccines represent a major breakthrough in the fight to control the disease. They have been extensively tested for safety and efficacy.(11,12) RotaTeq® (Sanofi Pasteur MSD) and Rotarix® (GSK) are licensed for young infants, but are currently not included in the national childhood immunisation schedule.

Conclusion
RV disease kills approximately half a million children under five annually in developing countries and accounts for one-third of hospitalisations for diarrhoea worldwide.(5) It is important for nurses to be aware of the direct and indirect costs of the consequences of this disease and to be ready to advise parents on the care of their children. Although the new vaccines may not eliminate the disease it is hoped, if they are made commonly available, that they will lessen the impact of the disease on children, on families and on the economy.

References

  1. Bishop RF, et al. Virus particles in epithelial cells of duodenal mucosa from children with acute non-bacterial gastroenteritis. Lancet 1973;2:1281-3.
  2. Parashar UD, et al. Rotavirus. Emerg Infect Dis 1998;4:561-70.
  3. Van Ranst M. Ever-changing rotaviruses: a never-ending story. Eur Rotavirus J 2005;1:10-1.
  4. Matson DO. In: Long SS, editor. Principles and practice of paediatric infectious diseases. New York: Churchill Livingstone; 2003.
  5. Parashar UD, et al. Global illness and deaths caused by rotavirus disease in children. Emerg Infect Dis 2003;9:565-72.
  6. Parez N. Rotaviruses: the clinical impact. Eur Rotavirus J 2005;1:8-9.
  7. Wiethoff CM, et al. Preventive measures against rotavirus infection. Eur Rotavirus J 2006;2:12-1.
  8. Gleizes O, et al. Nosocomial rotavirus infection in European countries. Pediatr Infect Dis J 2006;25 Suppl:12-9.
  9. Fischer TK, Bresee JS, Glass RI. Rotavirus vaccines and the prevention of hospital acquired diarrhea in children. Vaccine 2004; 22:49-54.
  10. Rheingans RD, et al. Economics of rotavirus gastroenteritis and vaccination in Europe: what makes sense? Pediatr Infect Dis J 2006;25 Suppl:48-55.
  11. Vesikari MD, et al.  Safety and efficacy of a pentavalent human-bovine (WC3) reassortant rotavirus vaccine. N Engl J Med 2006;354:23-33.
  12. Ruiz-Palacios GM, et al. Safety and efficacy of an attenuated vaccine against severe rotavirus gastroenteritis. N Engl J Med 2006;354:11-22.