Infectious diseases in children: Rotavirus

Modern immunisations and vaccination programmes mean that many of the childhood diseases that used to be common are now seldom seen. However, rotavirus is one of the exceptions that prove the rule — although with the addition of rotavirus vaccine to the childhood immunization schedule from September this year, it is hoped that its incidence will decline. In the meantime, here is advice on how to recognise and manage rotavirus

WHAT IS ROTAVIRUS

Rotavirus circulates in human and animal populations all round the world. There are five types, labeled A to E, of which A is by far the most common. Infection with one type does not confer complete immunity against the others — nor indeed lifelong immunity against the first — although subsequent attacks are less severe.

INCIDENCE AND PREVALENCE

The practice nurse will encounter rotavirus many times a year — because it is the most common cause of severe childhood diarrhoea in the UK — and indeed in the world. It will infect almost every child in the world at least once by the age of 5.

Rotavirus in the UK

While rotavirus is not usually a dangerous illness in UK practice, it hospitalizes 18,000 children a year,¹ (1 in 10 of all cases) and leads to a small number of deaths. It spreads rapidly, can cause schools and nurseries to be shut down, parents to take time off work, and it is a significant public health concern.

Rotavirus in the developing world

In the developing world virus is the same, but in conditions of poor infant nutrition compounded by lack of safe drinking water and limited or no access to medical care, it becomes lethal: rotavirus is responsible for over half a million annual child deaths, mainly of babies under two.² As a result WHO strongly recommends rotavirus vaccination in all countries where infant diarrhoeal illness accounts for 10% or more of infant deaths as part of a comprehensive strategy including improvements in hygiene and sanitization, zinc supplementation, and community based administration of oral rehydration salts.

SYMPTOMS

Rotavirus is most common in the winter.³ It is spread faeco-orally with an incubation period of only about 48 hours. Infection usually begins with fever and vomiting, followed by around three days of watery diarrhoea — although this can last as long as eight or nine days. Mild dehydration is common.

Clinical assessment of degree of dehydration can be difficult in small children but box 1 gives some guidance.

TELEPHONE TRIAGE

During rotavirus outbreaks the practice nurse may be involved in the telephone triage of children with diarrhoea. Mild cases of recent onset in children over six months old who are drinking and passing urine can often be given telephone advice unseen, but the practice should have a low threshold for seeing the following:

• Babies under six months
• Children with other ongoing medical conditions
• Children not tolerating oral fluids
• Children who are drowsy
• Children recently returned from abroad
• Children with diarrhoea for more than 5 days
• Children passing or vomiting blood
• Children with marked abdominal pain
• Children whose parents feel they are too ill for telephone triage

TREATMENT

There is no drug treatment per se. Treatment of rotavirus is symptomatic and usually supportive only — rehydration (usually by pushing oral fluids), persuading children to eat when they feel ready, managing fever and paying scrupulous attention to hygiene. More aggressive rehydration and support — nasogastric and intravenous rehydration — may be needed in severe cases.

PREVENTION

Vaccination in the UK

Until recently, rotavirus has not been felt to be a significant enough public health risk in the UK to warrant mass routine vaccination.⁵ However, from September 2013 it is to be added to our national vaccination programme.⁶ The vaccine consists of an oral spray given as two doses, four weeks apart. During trials, an earlier version of the rotavirus vaccine was associated with a slightly increased risk of intussusception (telescoping of a bowel segment, a serious condition usually triggered by enlarged bowel lymph glands). Because of this, although the risk is not seen with the newer vaccines, the recommendation is that the first dose is given between 6 and 15 weeks of age when natural susceptibility to intussusception is low.

ADVICE TO GIVE TO PARENTS²

Avoid spreading the infection

• Encourage your child to wash their hands after going to toilet
• Clean the potty or toilet thoroughly using disinfectant after each episode of diarrhoea and vomiting
• Wash your hands regularly, particularly after changing a nappy
• Do not share your child's towels, flannels or eating utensils
• Do not allow your child to return to nursery or school until 48 hours after the last episode of diarrhoea and vomiting
• Do not allow your child to go swimming (in a pool) for two weeks after their last episode of diarrhoea.

Manage dehydration

• Continue your child's normal diet and usual drinks. In addition, they should drink extra fluids. Avoid fruit juices or fizzy drinks, which can make diarrhoea worse
• Babies under 6 months old are at increased risk of dehydration. Speak to your GP. You may find that your baby's demand for feeds increases. You may also be advised to give extra fluids (water or rehydration drinks) between feeds. If you are breast-feeding, you should continue to do so
• If your child is mildly dehydrated, he or she may need rehydration drinks. Do not use home-made salt/sugar drinks, as the quantity of salt and sugar has to be exact
• If your child vomits, wait 5-10 minutes and then start giving drinks again, but more slowly (for example, a spoonful every 2-3 minutes). Use of a syringe can help in younger children
• If your child is not dehydrated (most cases) then encourage them to have their normal diet. Do not 'starve' a child with rotavirus infection. So:
  • Breast-fed babies should continue to be fed. This is in addition to extra rehydration drinks
  • Bottle-fed babies should be fed with their normal full-strength feeds in addition to extra rehydration drinks
  • Older children — offer food now and then. However, if they don't want to eat, that is fine. Drinks are more important, and food can wait until the appetite returns.

COMPLICATIONS

Aside from dehydration, the other transient complication is sometimes secondary lactose intolerance due to temporary loss of lactase production. This leads to a short-term intolerance of milk, which gets better when the infection is over and the intestinal lining heals.

SUMMARY

Rotavirus is very common. The practice nurse will have seen it many times, but is also likely to have had it as a child. It's essential to be clear on how to assess affected children for degree of unwellness, and clear with parents about how to manage diarrhoeal illness in their children, both regarding fluid intake, hygiene measures, and precisely what warning signs signify a need for medical review. The practice nurse is also likely to have a role in the forthcoming immunisation programme, which will hopefully mean we will see considerably less of the condition. Perhaps this will be the last such article you need to read!

REFERENCES

1. Estimating the number of deaths with rotavirus as a cause in England and Wales. Hum Vaccin. 2007 Jan-Feb;3(1):23-6. Epub 2007 Jan 18. Jit M, Pebody R, Chen M, Andrews N, Edmunds WJ.

2. World Health Organisation; Rotavirus infections: www.who.int/topics/rotavirus_infections/en/

3. Rotavirus: http://www.patient.co.uk/health/rotavirus

4. Steiner MJ, DeWalt DA, Byerley JS; Is this child dehydrated? JAMA. 2004 Jun 9;291(22):2746-54. [abstract]

5. Modelling and Economics Unit, Immunisation Department, Health Protection Agency, London, UK. mark.jit@hpa.org.uk

6. Vaccines today http://www.vaccinestoday.eu/vaccines/uk-vaccinated-babies-against-rotavirus/