This site is intended for health professionals only

Tackling rotavirus: the role of nurses

Recently available vaccines - now routinely used in the USA, Australia and other parts of Europe - may see rotavirus gastroenteritis prevented in the future. Their cost-effectiveness is now being considered in the UK. In the meantime, nurses can help to educate parents about this highly contagious but potentially life-threatening virus that is common during the winter months

Nicola O'Connell
BA(Hons)
Freelance Healthcare and Medical Writer
London

Rotavirus gastroenteritis, the most common cause of severe dehydrating diarrhoea in children worldwide, is highly contagious and incredibly resistant, making it particularly challenging to control.(1) Thus the recently available vaccines - RotaTeq (rotavirus vaccine [live, oral] - Sanofi Pasteur MSD) and Rotarix (rotavirus vaccine [human rotavirus, live, attenuated] - GlaxoSmithKline) - have the potential to make a significant impact on the spread of this virus that annually causes up to half a million deaths worldwide among children younger than five years of age, including an estimated 14 children in the UK.(2)
In the studies carried out to date, the rotavirus vaccines have been shown to be effective and protect against the five predominant rotavirus types that cause the majority of human rotavirus diseases: G1, G2, G3, G4 and G9. One study found these rotavirus types represented more than 98% of the rotaviruses found in the stool of children who sought care due to rotavirus infection.(3)
Phase III clinical trials for RotaTeq involved nearly 70,000 infants, including the Rotavirus Efficacy and Safety Trial (REST). In REST, RotaTeq demonstrated 98% efficacy against severe gastroenteritis caused by G1-G4 serotypes and reduced hospitalisation rates by 95.8%, and accident and emergency department visit rates by 93-97% in the vaccinated group for rotavirus gastroenteritis caused by serotypes G1-G4 targeted by the vaccine for up to two years after the third dose.(4)
Rotarix was studied in a major trial involving 63,225 infants. The efficacy of the vaccine against severe rotavirus gastroenteritis and against rotavirus-associated hospitalisation was 85% (P In the late 1990s, the first licensed rotavirus vaccine (RotaShield) was withdrawn from the US market less than a year after its introduction due to its association with intussusception, the most common cause of intestinal obstruction among children. Safety analysis within studies for RotaTeq and Rotarix looked for, but did not find, evidence of increased attributable risk for intussusception.
"Both of these vaccines cover the important strains of rotavirus and both fit into the immunisation programme very well," says Dr George Kassianos, a GP in Bracknell, Berkshire and fellow of the Royal College of General Practitioners. "The safety data are very good, compared to the risks associated with rotavirus gastroenteritis, and vaccine is well tolerated. Five countries have already introduced this vaccine on to their immunisation programmes: Austria, Belgium, Luxembourg, Australia and the USA. I would like to see the vaccine introduced into our programme in the UK as soon as possible."

Use of rotavirus vaccines
While the data for these rotavirus vaccines are arguably strong, questions certainly remain as to when - or indeed if - they will become part of the UK's immunisation programme. The Joint Committee on Vaccination and Immunisation (JCVI) has set up an expert subgroup to review the evidence on the benefits and cost-effectiveness of vaccinating children with rotavirus vaccine.
Two recent studies have been published evaluating the cost-effectiveness of rotavirus vaccination in England and Wales. The first study concluded that rotavirus vaccination has the potential to reduce this burden of disease.(6) The second study concluded that rotavirus immunisation could reduce the substantial short-term morbidity burden due to rotavirus - but is unlikely to be deemed cost-effective unless the vaccine is competitively priced.(7)

Rotavirus: clinical features
The rotavirus genus belongs to the Reoviridae family of viruses that can affect the gastrointestinal system and respiratory tract. A rotavirus has a characteristic wheel-like appearance by negative-stain electron microscopy; its name is derived from the Latin rota, meaning wheel.
Rotaviruses are nonenveloped, double-shelled viruses. The genome consists of segmented, double-stranded RNA (dsRNA) and each segment encodes a single protein. Rotaviruses are divided into seven groups (A to G) but most human rotavirus strains belong to Group A.(8)
The incubation period for rotavirus disease is approximately two days. The disease is characterised by vomiting and watery diarrhoea, with fever and abdominal pain occurring frequently.(1) In many cases children may have up to 20 episodes of vomiting and/or diarrhoea in 24 hours.(9) The symptoms can last up to eight days and some children are infected more than once by five years of age.
It was estimated that in one year 17,810 children in England and Wales were hospitalised due to rotavirus.(10) In a later review of the results of this study, it was estimated that one in 38 children under five in the UK would be hospitalised for rotavirus.(2)

Educating parents about rotavirus
Despite the fact that rotavirus is so common, awareness of the illness among parents is generally low. As such, parents may be unaware that rotavirus is potentially life-threatening. All parents should know how to look for the key signs of dehydration, including dry nappies, dark urine, sunken eyes, dry mouth, flushed skin and sunken fontanelle, and know when to seek immediate medical help.
"Parents often don't realise that younger babies do need to be given water, even if they are breastfeeding," says Sara Richards, Berkshire-based specialist primary care nurse. "It is best to give water little and often - every half hour or so, even if it is just a few drops into the infants' mouths."
Oral rehydration formulas (eg, Dioralyte) can be used to help provide the correct balance of water, salt and sugar lost through vomiting and diarrhoea.
"Parents need to rehydrate and rehydrate," says Dr Keith Lindley, consultant paediatrician gastroenterologist at the Institute of Child Health and Great Ormond Street. "The advice is to catch up on the last four hours of loss with rehydration. If four hours on parents haven't managed to keep up with the losses, and the child is showing signs of dehydration, then that's an indication that help should be sought."
NHS Direct advises giving children with rotavirus frequent sips of water or unsweetened fruit juice, even if they are vomiting. If the child wants to eat, then soup and foods high in carbohydrates (bread, pasta, potatoes) are recommended. But parents should be advised not to try to force the child to eat if he or she resists food.(11)

A stubborn bug - but good hygiene helps
Rotavirus is notoriously difficult to prevent; in fact, rotavirus can survive for weeks in potable and recreational water and it is relatively resistant to most soaps and disinfectants.(12-14) Just a small quantity of rotavirus - 10 virus particles per microlitre (ppm) - is enough to infect a child and provoke disease. Rotavirus-infected children excrete up to 10,000,000,000 virus particles per millilitre of faeces.(15)
The primary mode of transmission for rotavirus is faecal-oral, but low titres of virus in respiratory tract secretions and other body fluids have been reported.(1) As the virus is stable in the environment, transmission can occur through ingestion of contaminated water or food and contact with contaminated surfaces, such as toys.
Therefore, good hygiene is the best defence in at least minimising spread of infection as much as possible (particularly when there are other children in the household). It is worth reminding parents to wash soiled linen and clothing in as hot a wash as possible; keep soiled washing away from the rest of the washing; clean toilets and potties with bleach after use; and wash hands regularly.
Says Ms Richards: "It's worth reinforcing the message that it's important to wash hands after changing a nappy, and that when your child is ill, loo seats, door handles and so forth should be cleaned with antiseptic wipes. I would recommend regularly wiping areas in the bedroom and bathroom."

Conclusion
Currently, virtually every child is infected with rotavirus gastroenteritis before the age of five, and while the virus can cause few symptoms in some children, in others the symptoms are so severe that they need to be admitted to hospital. Rotavirus vaccines have shown significant promise in their efficacy and safety, and are now beginning to be used routinely in infants (but not yet in the UK). Nurses can, however, help parents to reduce the severity of rotavirus as much as possible by looking out for key signs of dehydration and practising good hygiene in an attempt to minimise spread of the virus.

References

  1. Centres for Disease Control and Prevention. Rotavirus. Available from: http://www.cdc.gov/rotavirus
  2. Parashar UD, Hummelman EG, Bresee JS, et al. Global illness and deaths caused by rotavirus disease in children. Emerg Infect Dis 2003;9:565-72
  3. Van Damme P, Giaquinto C, Maxwell M, et al. Distribution of rotavirus genotypes in Europe, 2004-2005; The REVEAL study. J Infect Dis 2007;195:S17-25.
  4. Vesikari T, Matson DO, Dennehy P, et al. Safety and efficacy of pentavalent human-bovine (W3C) reassortant rotavirus vaccine. N Engl J Med 2006;354:23-33.
  5. Ruiz-Palacios GM, Perez-Schael I, Velazquez FR, et al. Safety and efficacy of an attenuated vaccine against severe rotavirus gastroenteritis. N Engl J Med 2006;354:11-22.
  6. Harris JP, Jit M, Cooper D, Edmunds WJ. Evaluating rotavirus vaccination in England and Wales. Part I. Estimating the burden of disease. Vaccine 2007;25:3962-70.
  7. Jit M, Edmunds WJ. Evaluating rotavirus vaccination in England and Wales. Part II. The potential cost-effectiveness of vaccination. Vaccine 2007;25:3971-9.
  8. Parashar UD, Bresee JS, Gentsch JR. Rotavirus. Emerg Infect Dis 1998;4:561-70.
  9. Matson DO. In: Long SS. Ed. Principles and practice of paediatric infectious diseases. New York: Chruchill Livingstone; 2003.
  10. Ryan MJ, Ramsay M, Brown D, et al. Hospital admissions attributable to rotavirus infection in England and Wales. J Infect Dis 1996;174:S12-18.
  11. NHS  Direct. Rotavirus. Available from: http://www.nhsdirect.nhs.uk/articles/article.aspx?articleId=1810
  12. Ansari SPA, Springthorpe VS, Sattar SA. Survival and vehicular spread of human rotaviruses; possible relation to seasonality of outbreaks. Rev Infect Dis 1991;13:448-61.
  13. Raebel MA, Ou BS. Rotavirus disease and its prevention in infants and children. Pharmacotherapy 1999;19:1279-95.
  14. Fischer TK, Bresee JS, Glass RI. Rotavirus vaccines and the prevention of hospital-acquired diarrhea in children. Vaccine 2004;22:S49-54.
  15. Bishop R. Natural history of human rotavirus infection. Arch Virol Suppl 1996;12:119-28.