Published Date: 2003-11-14 23:50:00
Subject: PRO/EDR> Viral gastroenteritis update 2003 (25)
Archive Number: 20031114.2826
VIRAL GASTROENTERITIS UPDATE 2003 (25)
A ProMED-mail post
ProMED-mail is a program of the
International Society for Infectious Diseases
In this Update:
 Rotavirus (Jamaica)
 Norovirus (China, Hong Kong S.A.R.)
Date: Fri 14 Nov 2003
From: ProMED-mail <firstname.lastname@example.org>
Source: Morbidity and Mortality Weekly Report, Fri 14 Nov 2003 /
Jamaica: Outbreak of Severe Rotavirus Gastroenteritis Among Children
In late May 2003, the Jamaican Ministry of Health (MoH) identified a sharp
increase in the number of acute gastroenteritis (AGE) cases reported
throughout the country, accompanied by increases in AGE-associated hospital
admissions and deaths among children. The greatest increase in AGE cases
was observed among children aged <5 years in the southeastern parish of
Kingston and St. Andrew. During Jun to Jul 2003, 12 AGE-associated deaths
were reported among children aged <8 years.
The MoH began an investigation to determine the etiology of the outbreak,
ascertain risk factors for illness and death, and identify appropriate
control measures. This report presents the preliminary results of that
investigation, which determined that the AGE cases were associated with
rotavirus infection and deaths might have been reduced by appropriate AGE
case management, indicating a need for additional education of care-givers
regarding AGE treatment.
The increase in AGE cases was detected by Jamaica's National Sentinel
Surveillance System (NSSS), which receives weekly reports that include the
number of patient visits for AGE among children at 55 sentinel sites. In
addition, review of admissions at 2 Kingston and St. Andrew hospitals
identified an increase in the number of children hospitalized for AGE.
Mandatory investigation and reporting to MoH found a concurrent increase in
the number of diarrheal deaths among children.
Interviews with primary care-givers suggested that 8 of the 12 deaths were
attributable to diarrhea. These 8 deaths occurred among children aged 4
months to 3 years (mean: 17 months). All 8 children had watery diarrhea and
vomiting that began 1 to 5 days before death. All had visited a public or
private health-care provider at least once for treatment. 5 children had
received oral rehydration therapy (ORT) for their diarrheal illness; 3
received no ORT during their clinic visits. 3 children were treated with
antibiotics, 2 with antidiarrheals, and 3 with antiemetic injections.
Testing for _Salmonella_, _Shigella_, _Vibrio cholerae_, and _Escherichia
coli_ O157:H7 on 43 stool specimens collected during June to July as part
of NSSS surveillance identified 4 _Shigella_ spp. and 9 _Salmonella_ spp.
isolates. This was an expected finding for that time of the year. However,
rotavirus was identified by latex agglutination in 21 (49 percent) of the
initial 43 stool specimens and by enzyme-linked immunosorbent assay in 33
(50 percent) of an additional 66 stool specimens collected from children
aged <5 years as part of the MoH investigation. Further testing at CDC
identified rotavirus in five of seven stool specimens from persons aged >5
years. Testing of 32 stool specimens was negative for norovirus, sapovirus,
and astrovirus; however, adenovirus was identified in 3 specimens, all of
which also had evidence of rotavirus. Initial characterization of 23
rotavirus samples obtained as part of the MoH investigation indicated the
presence of 3 common serotypes; no vaccine strain was identified.
An epidemiologic investigation of this rotavirus-associated outbreak
continues to identify risk factors for severe illness and death. As of 12
Nov 2003, no food or water source had been identified. Preventive efforts
have focused on advising parents and physicians of the benefits of ORT for
children with AGE.
MMWR Editorial Note
In Jamaica, rotavirus is usually confined to winter months (1), occurs
among children aged <3 years, and is no longer associated with substantial
mortality. Identification of rotavirus as the etiologic agent of this large
outbreak of severe AGE seemed improbable, because the outbreak occurred
during the summer, included children aged >3 years, and resulted in
multiple deaths. However, laboratory tests confirmed rotavirus as the
etiologic agent, and identified multiple common rotavirus strains.
Environmental exposures are being considered as explanations for this
unusual outbreak. Ongoing studies are examining heavy rainfalls that
occurred in late May 2003 and might have flooded latrines in crowded urban
areas, causing fecal contamination of water sources. Community-wide
outbreaks of rotavirus attributed to fecally contaminated water have been
reported but are uncommon (2).
This outbreak underscores the importance of surveillance for rotavirus
disease. Rotavirus remains a major cause of diarrheal deaths worldwide (3),
many of which might be prevented by aggressive use of ORT (4) and vaccines
(5). The investigation of the outbreak in Jamaica suggested that
AGE-associated deaths might be attributable to inappropriate case
management. Certain children did not receive adequate ORT treatment, nor
was home use of ORT emphasized. Certain children received antiemetic and
antidiarrheal injections, which are not part of standard diarrhea
management. Additional education of physicians, parents, and other
care-givers regarding ORT can reduce the severity and mortality from
diarrhea during AGE outbreaks (6).
(1) Dowe G, King SD, Maitland PB, Swaby-Ellis DE. Laboratory investigations
on rotavirus in infantile gastroenteritis in Jamaica. Trans R Soc Trop Med
(2) Hopkins RS, Gaspard GB, Williams FP Jr, Karlin RJ, Cukor G, Blacklow
NR. A community waterborne gastroenteritis outbreak: evidence for rotavirus
as the agent. Am J Public Health 1984;74:263--5.
(3)Miller MA, McCann L. Policy analysis of the use of hepatitis B,
_Haemophilus influenzae_ type b-, _Streptococcus pneumoniae_-conjugate and
rotavirus vaccines in national immunization schedules. Health Econ
(4) Santosham M. Oral rehydration therapy: reverse transfer of technology.
Arch Pediatr Adolesc Med 2002;156:1177--9.
(5) Bresee JS, Glass RI, Ivanoff B, Gentsch JR. Current status and future
priorities for rotavirus vaccine development, evaluation and implementation
in developing countries. Vaccine 1999;17:2207--22.
(6) Walker GJ, Ashley DE, Hayes RJ. The quality of care is related to death
rates: hospital inpatient management of infants with acute gastroenteritis
in Jamaica. Am J Public Health 1988;78:149--52.
Date: Fri 14 Nov 2003
From: Matt Pottinger <Matt.Pottinger@awsj.com>
Source: ISD News, Fri 14 Nov 2003 [edited]
Hong Kong: Norovirus Implicated in Primary School Gastroenteritis Outbreak
The Department of Health (DH) is investigating a gastroenteritis outbreak
which affected some 150 students of a primary school. DH staff visited the
school in Central and Western District today (Fri 14 Nov 2003) and
yesterday. Investigations revealed that the sick students suffered from
vomiting, diarrhea and abdominal pain. 2 of them are admitted to hospital
in stable condition, while the others are resting at home. The school has
been under DH's medical surveillance. DH is contacting the students and
parents to ascertain their symptoms and collect stool samples. A stool
sample from a sick student tested positive for norovirus this afternoon.
Viral gastroenteritis caused by noroviruses is usually self-limiting with
symptoms of nausea, vomiting, diarrhea, abdominal pain, low-grade fever,
and malaise. The symptoms usually last for 24 to 48 hours. Viral
gastroenteritis is more common in winter months. In 2002, there were 9
reported outbreaks of norovirus-related viral gastroenteritis in primary
schools, affecting more than 300 students.
On an ongoing basis, DH issued Guidelines on Prevention of Communicable
Diseases to all child care centres, kindergartens, schools, and relevant
institutions. Following the gastroenteritis outbreak, DH staff provided the
school concerned with health advice on viral gastroenteritis and the proper
disinfection procedures. The school management carried out thorough
disinfection in the premises today and tomorrow under the supervision of
DH. All schools were also reminded of the precautionary measures to take in
preventing viral gastroenteritis in institutional settings.
A spokesman said that the infection can be transmitted via food or water
contaminated with the virus, contact with vomit or faeces from infected
people, contaminated objects, and spread by aerosol. With the approach of
the high season for viral gastroenteritis, DH is reminding schools to
watch out for students with symptoms of viral gastroenteritis and report
to DH if an outbreak is suspected.
Members of the public can obtain health advice on the prevention of the
viral gastroenteritis at DH's website <http://www.info.gov.hk/dh>.
The Wall Street Journal
[Matt Pottinger has pointed out that the norovirus outbreak in Hong Kong
follows mainland Chinese media reports (see: Viral gastroenteritis update
2003 (24) 20031112.2801) on apparent viral gastroenteritis in a school
in Guangdong province (which neighbors Hong Kong) and in Beijing. - Mod.CP]