Diarrhea due to Norovirus infection in children

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Illustration by Kompas Health

Norovirus is one of the viruses that play an essential role in the occurrence of acute diarrhea in children besides Rotavirus, especially in recent times which has involved many Rotavirus vaccine in children under five years of age. Acute diarrhea or gastroenteritis caused by Norovirus is usually associated with diarrhea outbreak in winter or a community with a high population density. Norovirus infection is also often transmitted from person to person.

It has become one of the causes of acute diarrhea in children in America that needs special attention because it causes a high number of hospital visits of around 900,000 visits per year and an increased number of hospitalizations of approximately 14,000—hospitalized patients annually. Norovirus infection has been known to be one of the most important causes of death with an estimated 70,000 to 200,000 deaths per year. However, data on the distribution of incidence and clinical manifestations of Norovirus infection itself is still limited in Indonesia. Therefore, we would like to analyze and describe the prevalence, clinical manifestations, and seasonal variations of diarrhea due to Norovirus infection in Indonesia, particularly in RSUD Dr. Soetomo, Surabaya.

We involved as many as 340 children in this study, especially children with primary complaints of diarrhea and diagnosed as acute gastroenteritis who were admitted to Department of Pediatrics, RSUD Dr. Soetomo, Surabaya, in April 2013 to March 2014. All pediatric patients included in this study were between 1 month and five years old. The sample was a fecal sample, the patients included in this study were patients who were willing to provide a stool sample, and the stool sample had to be a sufficient number for further analysis at Institute for Tropical Diseases (LPT), Universitas Airlangga, Surabaya.

The results of our study indicate that the prevalence of Norovirus infection is still relatively high with around 19% or about 64 children out of 340 children with acute gastroenteritis, especially in countries that have implemented Rotavirus vaccine, and 95% of them are under two years of age. Sixty out of 64 children who had gastroenteritis due to Norovirus infection had acute diarrhea, and the rest had persistent diarrhea. The most common symptoms of Norovirus infection in our study were fever, vomiting, abdominal pain, and convulsions. In contrast, the most common signs were flatulence, enlargement (distension) of the stomach, increased bowel peristalsis, and redness around the anus. As many as 79.7% of pediatric patients with Norovirus infection experienced diarrhea with the consistency of liquid feces. Besides, the seasonal variation of Norovirus infection occurs more frequently in November, May and April, compared to other months.

Moreover, Norovirus infection is common in children under two years old and is rarely found at the above age. The symptom that should be the primary consideration in diagnosing Norovirus infection is vomiting, so it is also appropriate in our study that vomiting is a typical symptom list. Another symptom of seizures is thought to be related to higher levels of viral particles in the feces of a child with Norovirus infection compared to Rotavirus infection. Still, the mechanism by which the virus passes to the brain remains unclear.

In addition to prevalence and symptoms, the majority of Norovirus infection is highly dependent on seasonal variations, especially the rainy season and winter. In the northern hemisphere, Norovirus infections are common from December to February, while in the southern hemisphere, conditions are even more expected from June to August. Our research also states the same thing that this relatively high Norovirus infection occurs during the rainy season in Indonesia, which is around December to February.

The conclusion is that diarrhea or acute gastroenteritis due to Norovirus infection in children is still common in Indonesia, especially those under two years old. This prevalence is increasing as a result of the high rate of Rotavirus vaccination. This infection also increases significantly during the rainy season. Therefore, diarrhea in children due to Norovirus infection certainly needs to be watched out for by countries in the world, especially in countries that have implemented the Rotavirus vaccine and countries with high rainfall in certain months.

Author: Dr. Alpha Fardah Athiyyah, dr., Sp.A (K)

Link: https://e-journal.unair.ac.id/JBE/article/view/14080 Athiyyah, AF, Wardhani, S., Dharma, A., Ranuh, RG, Raharjo, D., Shirakawa, T.,… Sudarmo, SM (2020). The clinical epidemiology of norovirus infection in children with diarrhea at Regional Public Hospital Dr. Soetomo. Periodic Journal of Epidemiology, 8(3), 200–207.

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