ROTAVIRUS INFECTION: Epidemiology, Disease Mechanism,

and Implication for Public Health in Indonesia

(A Review Paper)
Soegeng Soegijanto1, Oedojo Soedirham2
1
Institute Tropical Disease of Airlangga University Surabaya, Director of Mother and Child
Health Soerya Hospital, Sepanjang-Sidoarjo, East Java-Indonesia
2
Faculty of Public Health, Airlangga University, Surabaya, East-Java, Indonesia

Introduction
Rotavirus is recognized as the single most important cause of severe infantile
gastroenteritis worldwide. In the United States, these viruses are estimated to cause between
24.000 and 110.000 hospitalizations in young children annually and 20 to 60 deaths (Allen,
2010). Rotavirus is a leading cause of severe diarrheal disease and dehydration in infants and
young children throughout the world. Most symptomatic episodes occur in young children
between the ages of 3 months and 2 years. The virus spreads rapidly, presumably through
person-to-person contact, airborne droplets, or possibly contact with contaminated toys.
Transmission of rotaviruses occurs by the fecal-oral route, providing a highly efficient
mechanism for universal exposure that has circumvented differences in regional and national
cultural practices and public health standards. The symptoms associated with rotavirus disease
typically are diarrhea and vomiting accompanied by fever, nausea, anorexia, cramping, and
malaise that can be mild and of short duration or produce severe dehydration. Severe disease
occurs primarily in young children, most commonly between 6 and 24 months of age.
Approximately 90 percent of children in both developed and developing countries experience a
rotavirus infection by the time they reach 3 years of age. (Ward, 2010).
Rotavirus infection normally provides short-term protection and immunity against
subsequent severe illnesses but does not provide lifelong immunity; furthermore, numerous cases
of sequential illness have been reported. Neonates also can experience rotavirus infections, and
they occur endemically in some settings but typically asymptomatic. These neonatal infections
have been reported to reduce the morbidity associated with a subsequent rotavirus infection.
Rotavirus illnesses also occur in adults and the elderly, but as with other sequential rotavirus
infections, the symptoms usually are mild (Bhan, et al., 2006; Bishop, et al., 1973)

1
 Also reported from Indonesia by Sunarto et al. (2009) based on their study in 6 hospitals
(Jakarta, Palembang, Bandung, Denpasar, Mataram, and Yogyakarta) on 2006 found that 60% of
children under 5 years with diarrhea and hospitalized showed positive rotavirus. It also found in
41% diarrhea case who did not hospitalized.
Obviously, Rotavirus infection is a major cause of diarrhea in children under 5 years in
both the developed and developing countries. Rotavirus is often associated with acute infection
with high severity level that causes death. The genetic rotavirus, patient immunity, and
environmental thought to be related to the severity of the incidence of acute diarrhea due to
rotavirus in infants and young children.
The paper will review the epidemiology, pathogenesis, and the implication for public
health of Rotavirus.

Epidemiology
Rotavirus constitutes a genus within the Reoviridae, a family of non-enveloped,
icosahedral animal viruses with double-stranded, segmented RNA genomes. The family
Reoviridae also includes the reoviruses, which have occasionally been isolated from patients
with respiratory illness but have not been established as a cause of human disease, and the
coltiviruses, which cause disease in humans. Rotavirus is the most important cause of severe,
dehydrating gastroenteritis in children younger than 5 years in all socioeconomic groups and in
all region of the world (Parashar, Gibson, Bresee, et al. 2006). It is responsible for
approximately 611,000 infant and childhood deaths annually, with these deaths occurring
primarily in the developing world. In temperate climates, rotavirus cause the annual peak in
pediatric hospitalization for dehydration related to gastroenteritis during the cooler months of the
year (Cook, Glass, et al. 1990).

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 Figure.1.

Before the association of rotaviruses with human disease, etiologic agents were not
identified in most cases of childhood gastroenteritis. In 1973, electron microscopic examination
of duodenal biopsy specimens from six of nine children with acute gastroenteritis revealed
similar viral particles, which were approximately 70 nm in diameter (Holmes, Bishop, Davidson.
1973). Morphologically, these particles were indistinguishable from viruses previously
identified in specimens from mice and cows with diarrhea (Rhodes, Underdahl, Mebus, et al.
1969), and were designated rotaviruses because of their appearance in electron micrographs as
wheels with spoke. The antigenic similarity between the human and bovine agents was
confirmed when an exchange of matched liquid stool and convalescent-phase sera between a
veterinary and a medical laboratory showed that antibodies in the sera of children and calves
agglutinated the rotavirus particles in the stool of both species (Flewet, Bryden, Davis, et al.
1974). The human sera also neutralized the infectivity of the bovine agents, which had been
adapted to growth in cell culture.
Since the discovery of the agents, understanding of rotavirus replication, pathogenesis, and
immunity has relied on the study of strains that grow well in cell culture and on large and small
animal models for rotavirus infection and disease. The ability to mate rotavirus strains by

3
coinfecting cells to achieve reassortment of the 11 genome segments has allowed classic genetic
studies. Extensive global epidemiology has relied on an elaborate serology, now supplemented
by nucleic acid-based diagnostics. This scientific background enables the recent introduction of
live-attenuated vaccine for human use. These vaccines have started to change the epidemiology
and clinical impact of rotaviruses in the regions where they are being introduced (Centers for
Disease Control and Prevention, 2008). Extension of effective immunization to the most
severely affected populations in developing countries is the next important challenge. The
application of molecular and structural biology promises to provide the scientific basis for the
next generation of vaccines.

Figure 2.

In addition to restrictions in interspecies transmission of rotaviruses, age restrictions are

associated with rotavirus disease. In animals, rotavirus illness appears to be limited to the first
days or weeks of life (Bridger and Brown, 1981). Mice are susceptible to rotavirus infection for
their entire lifetime. Similarly, piglets and calves are most susceptible to rotavirus infection for
their first 15 days of life but can experience a rotavirus infection for their entire lifetime. In

4
contrast, severe human rotavirus disease occurs most commonly in infants between 6 and 24
months of age, but milder rotavirus illness occur throughout our lifetimes.
Causes for the reduced severity of rotavirus disease before 6 months and after the first
years of life continue to be subjects of intense investigation. Possibly, non-immunologic, age-
dependent changes that occur within the intestine, including an observed decrease in virus-
specific receptors on enterocytes between suckling and adult mice, could account for this
reduced severity. A similar suggestion has been made for claves. This suggestion also may help
explain why human infants are more susceptible to rotavirus illness than are older children or
adults. Decreased concentrations of proteases needed to cleave the VP4 protein in intestinal
secretions of newborns relative to older infants also could help explain the resistance of neonates
to rotavirus disease.
Neonatal rotavirus infections are common occurrences. On the basis of sequence analyses,
researchers proposed that neonatal strains possess unique VP4 genes, which have been classified
as genotype P[6]. Because neonatal rotavirus infections also typically asymptomatic, rotavirus
containing P[6] VP[4] genes were designated neonatal or asymptomatic strains. Further
epidemiologic studies have shown that these descriptions are not accurate; that is, asymptomatic
neonatal infections sometimes are caused by non-P[6] strains, and many symptomatic infections
of older infants are caused by P[6] strains. In fact, P[6] rotaviruses are probably the third most
common P genotype associated with rotavirus illness worldwide today. Therefore, why most
neonatal rotavirus infections are caused by P[6] strains and whether the P[6] genotype is in any
way responsible for the asymptomatic phenotype of these infections remain unclear. However,
the virulence of P[6] stains found in Africa neonates was associated with genetic differences in
the genes encoding not only VP4 but also VP7 and NSP4, suggesting a possible linkage between
multiple rotavirus genes and the virulence of neonatal strains.
The onset of rotavirus disease in infants has been reported to coincide with the decline of
maternal IgG antibody titers to low concentrations. Furthermore, excellent correlations have
been observed between responsiveness to the live rotavirus vaccine Rotarix and transplacental
neutralizing antibody titers to the vaccine strains. Therefore, the commonly asymptomatic nature

5
 Figure 3.

of neonatal rotavirus infections may be due at least partially, to protection from transplacental
antibody that may persist for the first months of life (Bernstein, Smith, Sander, et al. 1990).
Mechanisms by which transplacental maternal antibody might protect against intestinal infection
are unclear. Passive transfer of neutralizing antibody to the intestine of both human and animals
is associated with protection, but circulating anti-rotavirus IgG appears to confer little if any
protection in animals. Posibly, maternal IgG in humans is taken into the intestine, where it
neutralizes rotavirus before infection. Regardless of why rotavirus infection of neonates
typically is asymptomatic, these infection have been found to reduce the severity of rotavirus
illness in older infants (Bhandari, Sharma, Glass, et al. 2006). For these reasons, two rotavirus
strains obtained from neonates were developed initially as vaccine candidates (Barnes, Lund,
Adams, et al. 1997), and two others obtained from India, have been evaluated recently in a safety
and immunogenicity study.
The reduced severity of rotavirus disease in older children and adults probably is due
primarily to immune responses stimulated by previous rotavirus infections. In developed as well
as in developing countries, almost all human experience at least one rotavirus infection by the
time they reach 3 years of age, and circulating rotavirus antibody remains detectable indefinitely.
Protection against rotavirus infection and disease in children and adults has been correlated with
titers of both circulating and intestinal rotavirus antibody. Although these antibodies have not

6
been established as the effectors of protection, their presence indicates a natural infection that has
elicited a protective immune response.
As with respiratory and enteric viruses, distinct seasonality is associated with rotavirus
disease. It is particularly evident in temperate climates, where rotaviruses probably are
responsible for the large increase in diarrheal deaths that occur during the winter season. The
seasonality of rotavirus disease is less apparent in tropical climates but is still more prevalent in
the drier, cooler month. The cause for the seasonality of rotavius disease is a topic of
considerable interest but remains unknown.
The transmission of rotavirus infections is thought to be fecal oral, with little evidence of
airborne transmission. Yet a unique pattern of rotavirus infections that follows the general
direction of the prevailing winds is observed annually in North America. These infections begin
in Mexico and the Southwestern United States in mid to late fall and travel systematically across
the continent, ending in the northeastern United States and Maritime Provinces of Canada in the
spring. Until recently, this was the only description of a repetitive geographic sequence for the
seasonal epidemic activity of a viral agent. However, a similar pattern of rotavirus spread was
reported for Western Europe, where the seasonal peak started in Spain in January and ended in
the more northern countries in March. These annual events, including wind movements, have no
satisfactory explanation. The phenomenon appears to be independent of latitude, which argues
against temperature-dependent associations and humidity. Furthermore, the electropherotypes
and serotypes of isolates found in different geographic locations can vary, a counterindication for
a gradual, physical transmission of rotavirus infections as a wave to the north and east.
Because rotavirus illness occur with seasonal regularity and decrease to almost
undetectable levels during the off-seasonal, the virus must be retained in a less active state during
most of each year. Retention of human rotavirus in animal reservoirs between seasons is
unlikely because of the low interspecies transmissibly associated with this virus, as already
discussed. Therefore, the virus may continue to replicate at low levels in human until conditions
are favorable for the annual epidemic. The occasional rotavirus illnesses that occur in the off-
season support the suggestion the human are a reservoir. It is also possible that the virus survives
in the environment, which provides continuous exposure throughout the year but result in
sustained rotavirus illnesses only during seasonal epidemics. Rotaviruses are shed in extremely
high concentration (i.e., approximately 1011 particles/g of human feces), retain infectivity for

7
many months at ambient temperatures, and are detectable readily on environmental surfaces
(Butz, Fosarelli, Dick, et al. 1993). Therefore, the environmental could be a reservoir for human
rotavirus and a possible source for the initiation of seasonal epidemics.
The provided clues about the origin of rotavirus strains responsible for epidemics, many
extensive studies have been performed to characterize the circulating viruses, primarily using
electropherotypes, genotypes, and serotypes. From, these studies, investigators have determined
that rotavirus strain in a specific locale can vary little over sequential seasons or change
dramatically, even within a single season. Furthermore, multiple strains often present within a
region at any period during an epidemic. Because gene re-assortment can be extensive after co-
infection with rotavirus, identification of the source of new strains within a defined geographic
area is difficult. They could be derived from outside sources, they could be obtained from local
reservoirs, or they could arise by gene re-assortment of circulating strains. Clearly, if the source
of virus responsible for initiating annual rotavirus epidemics could be identified, much would be
learned about the epidemiology of rotavirus.

PATHOLOGY AND PATHOGENESIS

After fecal-oral transmission of rotavirus, infection is initiated in the upper intestine and
typically leads to a series of histologic and physiologic changes. These changes have been
examined extensively, particularly through experimental infections of animal. Studies in calves
revealed that rotavirus infection caused the villus epihitelium to changes from columnar to
cuboidal, which resulted in shortening and stunting of the villi. The cells at the villus tips
became denuded; in the underlying lamina propia, the numbers of reticulum-like cells increased
and mononuclear cell infiltration was observed. The infection started at the proximal end of the
small intestine and advanced distally. The most pronounced changes usually, but not always,
were associated with the proximal small intestine. When bovine rotaviruses of different
virulence were intestine poorly but infected more villus enterocytes in the mid and distal
intestine than did the high-virulence strain (Bridger, Hall and Persons. 1992). Although the low-
virulence strain replicated in these calls and caused cytopathic effects, it did not damage the
intestinal structure or affect function. Similar observations were made after piglets were infected
with rotavirus.

8
 The pathology of murine infection also has been examined in several studies, and the
results are similar to those found in large animals (Adams and Kraft, 1967). Many of these
studies have been conducted with heterologous rotavirus strains that require infection with much
greater quantities of virus because of the restricted replication of these viruses in mice (Bell,
Clark, Brien.,et al. 1987). The histologic changes induced by these heterologous strains are
similar to those found after murine rotavirus infection, even though viral replication is limited
after oral inoculation with these viruses. Mice are susceptible to rotavirus diarrhea during their
first 2 week of life, and recently a series of strikingly clear result on murine rotavirus infection in
neonatal mice were reported (Boshuizen, Reimerink, Korteland. 2003). They included time-
dependent histologic changes in the intestine, kinetics of rotavirus replication, shortening of
intestinal villi, induction of apoptosis, and alterations in cell migration kinetics.
Studies with the mouse model also have revealed a potential hazard associated with the
possible use of heterologous viruses as vaccine candidates. Although replication of the
homologous strains appeared to be restricted to the intestine, oral inoculating of either mice with
severe combined immune deficiency (SCID) or normal mice with a simian rotavirus resulted in
its spread to the liver and induction of hepatitis. Because of evidence that shows abnormal liver
function occur during natural rotavirus infection in humans, this observation caused concern
about the use of animal strains as vaccine candidates. However no significant alteration of liver
function has been associated with any rotavirus vaccine candidates have been derived from
animal rotavirus strains. As discussed in detail in a letter section, however, use of the same
simian rotavirus strain in combination with three monoreassortants of this virus as a vaccine in
infants ws found to increase the incidence of intussusceptions in the week after administration of
the vaccine from the market.
A few studies have examined the pathologic changes in the intestines of humans, but the
result appeared to be similar to those found in animals. Tissue tropism rotavirus infection in
human also appeared to be restricted normally to villi of the small intestine. Sporadic instances
of nongastrointestinal rotavirus-associated disease, including the association with abnormal liver
function mentioned before, as well as respiratory and nervous system involvement have been
reported. However, because no consistent evidence of extraintestinal replication of rotavirus had
been forthcoming, the general assumption was that rotavirus disease is strictly intestinal. This
assumption, however, change dramatically in 2003 when both antigenemia (presence of rotavirus

9
protein in the blood) and viremia (presence of live rotavirus in the blood) were found during
rotavirus infection in several strains of animal and in human. Since that time, this observation
has been confirmed with a number of studies that included several in humans (Azevedo, Yuan,
Jeong. 2005). On the basis of these observations, the possibility that rotaviruses are a common
caused of a variety of nonintestinal disease has gained impletus and will be a subject of intestine
investigation in coming years.
As with host-range restriction, the molecular basis for pathogenicity has not-been
established. Office and cowokers reported that the virulence of reassortants generated between
heterologous rotaviruss and tested in a mouse correlated with the presence of the VP4 proteins
from the more virulent virus. Neither rotavirus strain used this study (a simian and a bovine
strain) replicated efficiently in mice, however, suggesting that the observation may have limited
applicability. A later study with murine simian rotavirus reassortants revealed no association
between the VP4 protein and virulence (Broome, Ward., et al. 1993). In that study, the strongest
association between virulence and a gene product was with NSP1, a nonstructural protein.
Association between virulence and specific gene segments also were examined in piglets.
Virulence variants that appeared to differ only in their VP4 genes were isolated from the feces of
an infected pig (Bridger, Burke, Beards, et al. 1992). To eliminate the possibility that virulence
was determined by other gene products, the VP4 gene of the virulence strain was transferred into
the avirulent strain by reassortment. This transfer caused the avirulent strain to become virulent.
In another study with reassortants between a virulent porcine virus and a human strain attenuated
for piglets, investigators found that the porcine rotavirus genes encoding VP3, VP4, VP7, and
NSP4 were required for virulence in piglets. Whether either of these observations has general
applicability or pertains only to a limited combination of rotavirus strain because of specific
interactions among their proteins remains to be determined. Passage of a porcine rotavirus in
piglets was reported to increase its virulence dramatically (Ball, Peng, and Estes. 1995), whereas
passage of a virulent porcine rotavirus in cell culture attenuated this virus. Thus, the associations
between specific rotavirus genes and virulence can be altered readily by natural selection through
mutation. Until very recently, one could not make specific nucleotide changes within rotavirus
genes and re-incorporate the modified gene into new infectious rotavirus particles. However, a
system of reverse genetics for has now been reported, at least for the rotavirus gene segment
encoding VP4. Expansion of this system of reverse genetic to the other rotavirus genes should

10
permit investigators to identify specific amino acid and protein structural changes that are
responsible for rotavirus virulence and attenuation.

MECHANISMS OF DIARRHEA
Although rotaviruses causes severe diarrhea in numerous species, including humans, the
mechanisms responsible have not been determined and may be due multiple factors. An early
study in piglets indicated that net sodium and calcium fluxes were not different between control
and infected animals, but glucose mediated sodium absorption was diminished by rotavirus
infection. On the basis of this and other physiologic changes, it was concluded that retarded
differentiation of uninfected enterocytes that migrated at an accelerated rate from the crypts after
the virus had invaded villus calls was responsible for absorptive abnormalities. Another study
with piglets led to the conclusion that destruction of the villus tip cells caused carbohydrate
malabsorption and osmotic diarrhea. In mice, researchers reported that carbohydrate
malabsorption did not occur as in piglets and, therefore, crypt cell secretions may be the cause of
fluids loss. Intestinal prostaglandin E2 concentrations were reported to be elevated after rotavirus
infection of piglets, leading to the suggestion that prostaglandin E may be a secretory component
of diarrhea in this animal model. Additional studies in animal and humans concerning changes
in the absorption of macromolecules across the intestinal surface after an episode of rotavirus
infection have revealed no general pattern. Uptake of some molecules, such as horseradish
peroxidase and 2-rhamnose, is increased; uptake of other molecules, such as lactulose and D-

xylose, is decreased. Therefore, the relationship between the absorptive properties of intestinal
mucosa of diarrhea remains unclear.
The importance of virus replication for induction of rotavirus diarrhea also has been
challenged. Inoculation of mice with heterologous rotaviruses had been observed to produce
diarrhea only when mice were inoculated with large quantities of these viruses, and in these
cases, diarrhea occurred despite a lack of efficient viral replication (Bridger, Burke, Beards, et al.
1993). Subsequently, inoculation with a large number of inactivated particles from a
heterologous rotavirus was reported also to result in diarrhea. The authors suggested that
rotavirus attachment or entry into cells was sufficient to induce diarrhea in this model and that
the mechanism of rotavirus- induced diarrhea was consistent with a viral toxin-like effect exerted
during virus cell contact.

11
 Diarrhea also has been induced in infant mice and rats by interperitoneal inoculation with
the rotavirus NSP4 protein as well with a 22-amino acid peptide derived from this protein (Ball,
Peng, and Estes. 1995). Investigators observed that this protein and its peptide caused an
increase in calcium concentration in insert cell when added exogenously. In subsequent
experiments, NSP4 and its peptide were found to increase the levels of intracellular calcium, by
activating a calcium- dependent signal transduction pathway that mobilizes transport of this ion
from the endoplasmic reticulum. Further reports suggest that NSP4 processes membrane
destabilization activity (Browne, Bellamy, and Taylor. 2000), that may result from increased
intracellular calcium concentration, resulting in cytoskeleton disorganization and cell death.
Thus, binding of NSP4 is the enteric nervous system, which lies under the villus epithelium.
Rotavirus infection has been shown to activate this system in mice, and drugs that block nerve
activity attenuate rotavirus- induced fluid secretion in vitro and attenuate diarrhea in vivo.
Whether this is a major mechanism of diarrhea occurring after rotavirus infection remains to be
determined. Some additional studies in mice support a role for NSP4 as a cause of diarrhea,
whereas others indicate that mutation in NSP4 are not responsible for attenuation of rotavirus in
either mice humans (Angel, Tang, Feng, et al.1998), thus questioning its importance as a cause
of diarrhea in nature.

IMMUNITY
Much has been learned about the immune response to rotavirus, but the key question of
what provides protection from infection or disease remains unanswered. Rotavirus infections
clearly induce a humoral immune response beginning with production og IgM antibodies and
later including IgA and IgG antibody. Infection also includes local, intestinal antibodies there are
predominantly IgA but also include IgG and IgM initially. After infection develops in mice, as
many as 50 percent of all IgA-producing B cells in the lamina propia of the intestine can be, for a
least a brief time, rotavirus specific. Cell-mediated immunity, including lymphoproliferative
responses, also can be detected transiently after infection develops in adult humans, and a brisk
cytolytic T-cell response (CD8+) has been found in the intestines and spleens of infected mice.
The most immunogenic protein appears to be VP6. Thus, antibodies measured by enzyme-
linked immunosorbent assay (ELISA) are directed mainly at this protein, but they are not
neutralizing antibodies. Some evidence suggest, however that IgA antibodies directed at VP6

12
can be protective by mechanisms that are not completely understood but may involve intacellular
inhibition of rotavirus replication within infected enterocytes during polymeric antibody
transport to the intestinal lumen.

CLINICAL MANIFESTATIONS
Rotavirus is the most common cause of dehydrating diarrhea in children in the United
States and worldwide and infects nearly every child in the first few year of live (Bresee, Fang
Wang, et al,. 2004). In the United States, more than 600.000 cases of severe diarrhea are caused
annually by rotavirus, resulting in 20 to 60 deaths. An estimated 1 in 80 children younger than 5
years in hospitalized, and 1 in 7 requires an outpatient or emergency department visit because of
rotavirus diarrhea. A world wide estimated 610.000 deaths are associated with rotavirus
infection. The incidence of rotavirus infections is highest in children between the ages of 6 and
24 months, but the age may be lower in less develop countries. Adult, including elderly patients,
also are susceptible to re-infection, which can cause mild and sometimes severe disease.
Initial and subsequent rotavirus infections often are asymptomatic. In cohort studies in
which infants were observed from birth, as many as 50 percent of initial rotavirus infections were
asymptomatic. In one report, a carrier state was described (Champosaur, Questiaux, Prevot, et al.,
1984). Reports of neonatal infections that are asymptomatic in selected settings are common
(Bhan, Lew, Sazawal, et al).
The incubation period for rotavirus is approximately 1 to 3 days. In children with
asymtoms, the onset often is abruot, with fever and vomiting followed by explosive, watery
diarrhea. Vomiting may precede the diarrhea in approximately half the cases, stool are not-
bloody and generally lack fecal leukocytes, but mucus may be found in 20 percent. Fever occurs
commonly during rotavirus illness, with estimates of between 45 and 84 percent of patients. The
disease usually is self-limited last in 4 to 8 days, although the duration of symptoms ranged
between 2 and 22 days in Guetemalan study. In one cohort study children with asymptomatic
disease, 62 percent had mild disease, 35 percent had moderate disease, and 3 percent had severe
disease;7 percent of children required hospitalization. In another study, 64 percent of children
with rotavirus diarrhea had vomiting, 64 percent had fever, 14 percent were dehydrated, and 18
percent were hospitalized. In children hospitalized with rotavirus infection, 63 percent had fever,
vomiting and diarrhea at presentation; children also presented with any two or only one of these

13
symptoms. When hospitalization is required, the stay usually is brief, with an average of 4 days
and a range of 2 to 14 days. Recovery generally is complete, but persistent diarrhea associated
with lactose intolerance has been described (Beatttie, Vieira, Philips, et al., 1995).
In general, rotavirus infection is more severe than are those caused by other viral
gastrointestinal agents (Bernstein, Smith, Sander, et al., 1990). In developing countries, 20 to 40
percent of hospitalizations for diarrhea in children younger than 5 years are due to rotavirus
infections, whereas in the United States, rotavirus is estimated to account for between one third
and two thirds of admissions for diarrhea in children (Brandt, Kim, Rodriques, et al., 1997).
Vomiting, dehydration and hospitalization occur significantly more often in patients infected
with rotavirus than in those with other causes of diarrhea. In one study vomiting and diarrhea
also lasted longer in patients infected with rotavirus (2.6 versus 0.9 days and 5.0 versus 2.6 days,
respectively). In another study, the severity score for rotavirus diarrhea was almost twice that of
disease having other causes.
In children with dehydration caused by rotavirus, dehydration was more likely to be
isotonic than was dehydration caused by other agents. However, in another study, one fourth of
the patients infected with rotavirus presented with hypernatremic dehydration. Other reported
findings in children with rotavirus include irritability and pharyngeal or tympanic membrane
erythema. Numerous reports associate respiratory symptoms (e.g, cough, pharyngitis, otitis
media, and pneumonia) with rotavirus infections, but the relationship of these symptoms to
rotavirus is unclear, and the ability to isolate rotavirus from respiratory secretions has varied
among studies. Laboratory findings are releted mostly to the extent of dehydration and can
include elevated blood urea nitrogen and evidence of mild metabolic acidosis.
The peak viral shedding in stool occurs on approximately day 3 of illness. When it was
evaluated by polymerase chain reaction (PCR), the duration of rotavirus shedding ranged from 4
to 57 days in hospitalized patients. Approximately half of the children shed for fewer than 10
days and 70 percent for fewer than 20 days. In Guetamala, prolonged viral shedding also has
been reported for as long 5 weeks was associated with immunodeficiency.
Other clinical manifestation associated either etiologically or incidentally with rotavirus
infection have been describe and include encephalitis and meningitis; various upper and lower
respiratory infection, including otitis media, laryngitis, pharyngitis and pneumonia; Kawasaki
syndrome; sudden infant death syndrome; hepatic abces; and pancreatitis. Elevated liver

14
function test a result also have been reported during rotavirus infection. Neonatal necrotizing
enterocolitis also has been linked with rotavirus. However, the difficulty of false-positive
reactions obtained with some ELISA test in neonates must be considered (Chrystie, Totterdell,
and Banatvala, 1983). Rotavirus infections can be more severe in immunosuppressed persons,
including bone marrow transplant recipients, patients infected with human immunodeficiency
virus, and those who are malnourished, and they may spead to the liver and kidney. Of interest,
rotavirus antigen recently been reported to be found also in the blood of immunocompetent
children with confirmed rotavirus gastroenteritis. The role that circulating rotavirus may have in
these extraintestinal manifestation is intriguing but unkwon.
In the past, central nervous system involvement associated with rotavirus infections,
including aseptic meningitis, and encephalophaty, was determined by electron microscopy and
antigen detection through immunologic methods. However, more recently, cases have been
reported by identification of rotavirus RNA in the cerebrospinal fluid with use of reverse
transcription-polymerase chain reaction (RT-PCR) analysis. Rotavirus RNA has been found in
the cerebrospinal fluid in rotavirus-infected children with seizures, encephalitis, and
encephalopathy. Of the 20 reported cases, 15 wrw reported to have full recovery, but three had
significant neurologic complications and two children died. Each of these report suggest that
rotavirus may have a spectrum of organ involvement and disease that extends beyond the
gastrointestinal tract.
The relationship between intussusceptions and natural rotavirus infection is of great
interest because of the reported link between the tetravalent RRV vaccine and intussusceptions
(discussed in the section on vaccine). Several studies have investigated the possible infectious
etiology of intussusceptions (Bhisitkul, Todd and Listernick. 1992). Given the rarity of
intusseception, these studies have been identified in these case series. Adenovirusses have been
recovered most often (Bhisitkul, Todd and Listernick. 1992). Although several studies have
argued that the lack of seasonal variation for intussusceptions suggest that wild-type rotavirus
does not cause intussusceptions, the possibility remains that many intestinal pathogens, including
rotavirus, may cause intussusceptions and multiple agents may account for the lack of a seasonal
peak.
Infants and young children with diarrhea caused by rotavirus are more likely to have severe
symptoms and become dehydrated than patients with diarrhea related to other common enteric

15
pathogens (Konvacs, Chan, Hotrakitya., et al.). The clinical features of rotavirus gastroenteritis
in humans have been studied in experimental infections in adult. In one such, 4 of 18 adult
volunteers develop vomiting 1 to 3 day after oral administration of a virulent rotavirus strain
(Kapikian, Wyatt, Levine, et al.1983). This was followed by diarrhea lasting 1 to 4 days and
associated with anorexia, crampy abdominal pain, and low grade fever. Viral shedding in stool
was detected for 6 to 10 or more days. Two thirds of the adult volunteers developed serologic
evidence of infection without disease. Similarly, most natural rotavirus infection of adult is
asymptomatic, manifested only by a rise in antibody titer (Kim, Brandt, Kapikian, et al., 1977).
However, natural rotavirus infection of adults can also causes severe and even fatal disease
(Hrdy, 1987).
Observational studies of children in North America hospitalized with roravirus
gastroenteritis reveal a similar, although more severe, pattern of disease (Rodrigues, Kim,
Arrobio, et al.1997). Rotavirus gastroenteritis in children generally begins with vomiting and
fever, which lasts 2 to 3 days, and progresses to profuse watery vomiting and fever, which
continues for 4 to 5 days. Vomiting is more common and prolonged with rotavirus
gastroenteritis than with pediatric gastroenteritis caused by most other agents.
Laboratory findings in children hospitalized with rotavirus gastroenteritis reflect isotonic
dehydration and include a high, urine-specific gravity and metabolic acidosis (Konvacs, Chan,
Hotrakitya, et al. 1987). Rotavirus gastroenteritis is not generally associated with leukocytosis
but is sometimes accompanied by a mild elevation in transminases and uric acid levels. Liquid
stool from children with rotavirus diarrhea usually do not contain blood or fecal leukocytes,
although the presence of fecal leukocytes does not axclude rotavirus as an etiology (Rodrigues,
Kim ,Arrobio., et al.1977). Typically, virus is detected in stool of children by antigenic assay for
4 to 10 days after the onset of symptoms. When a asensitive reverse transcriptase-polymerase
chain reaction (RT-PCR) assay is used, shedding of viral RNA can be detected for up to 57 days
from immunocompetent children, although this does not necessarily indicate shedding of
infectious particles (Carlson, Middleton, Szymanski, et al. 1978).
Dehydration and severe electrolyte abnormalities leading to cardiovascular failure are the
most common proximate causes of death from rotavirus gastroenteritis (Carlson, Middleton,
Szymanski, et al. 1978).

16
 Seizures and aspiration of vomiting may also lead to death. In a case series from Toronto,
parents of 16 of 21 infants and young children who died from rotavirus gastroenteritis had made
contact with a physician during the course of the illness. Nevertheless, after a median 2 days of
illness, 20 of the 21 ultimately presented to the hospital either dead or moribund. In a number of
cases, communication barriers between physician and parent related to language or culture may
have contributed to the fatal outcomes. (Carlson, Middleton, Szymanski, et al., 1978).
The spectrum of illness after rotavirus infection of infants and children also includes mild
gastroenteritis and asymptomatic infection. In some newborn nurseries, difficult-to-eradicate
endemic rotavirus strains asymptomatically infect neonates year round (Rodger, Bishop, Birch,
et al.1981). A common VP4 type P[6] and genetic stability over time suggest that these nursery
strains may be less virulent that most circulating strains, although maternally transmitted
immunity or maturational resistance may also protect the neonates from disease. Because
outbreaks of rotavirus diarrhea in neonatal nurseries also occur, any component of maturation
resistance cannot be absolute (Widdowson, Doornum, Poel, et al. 2002).
Rotavirus also has eextraintestinal manifestation. Viremia, which is common is
symptomatic and asymptomatic rotavirus infection, has unknown clinical signifycance in
immunocompetent children (Blutt, Matson, Crawford, et al. 2007). In immunocompromised
children, rotavirus infection has been associated with chronic diarrhea and extraintestinal
infection. Conditions associated with chronic rotavirus infection include severe combined
immunodeficiency (SCID), X-linked agammaglobulinemia, carlilage hair hypoplasia, acquired
immunodeficiency syndrome (AIDS) and DiGeoge Syndrome (Oishi ,Kimura, Murakami,et
al.1991). Rotavirus shed from chronically infected children often has altered genome segments
(Wood, David, Chrystie .,et al.1988). Immunohistochemical staining for rotavirus structural and
nonstructural proteins in autopsy specimens has demonstrated rotavirus replication in the
hepatocytes and renal tubular cells of immunodeficient children with chronic rotavirus infection
at the time death. Relatively severe rotavirus gastroenteritis has been noted in adult in-patients
with immunosuppression related to bone marrow or renal transplantation. Rotavirus is
associated with diarrhea in adults with AIDS and very low CD4 counts but is not one of the more
common on causes of diarrhea in this population.
Rotavirus has been detected in association with a number of syndromes other than
gastroenteritis, including respiratory infections, necroting enterocolitis, pneumatosis intestinalis,

17
hepatic absess, myocarditis, seizures, and meningoncephalitis. As rotavirus infection in
universal, this association may be coincidental rather than causative, and an etiologic association
has not been established. Although intestinal intussusceptions has been temporally associated
with immunization with Rotashield, a live-attenuated rotavirus vaccine no longer on the market
(see immunization) intestinal intusception does not appear to be associated with natural
rotavirus infection.
Links between rotavirus infection and the subsequent development of autoimmune disease
have been proposed. Although some strains of rotavirus can cause biliary atresia in mouse
models, and group C rotavirus has been detected in liver tissue from biliary atresia patients,
rotavirus has not been convincingly demonstrated to cause this conditional in humans. Similarly,
depending on timing, rotavirus infection can either accelerate or delay the onset of diabetes in
nonobese diabetic (NOD) mice, but rotavirus infection has not been significantly associated with
the development of type 1 diabetes in humans. Serologic evidence of more frequent rotavirus
infection has been associated with the development of celiac disease in predisposed children.
The introduction of effective rotavirus immunization will clarify whether symptomatic infection
with Group A rotaviruses is a trigger for such distinctive clinical syndromes.

DIAGNOSIS
Rotavirus gastroenteritis is not clearly distinguished from other causes of acute
gastroenteritis on clinical grounds alone. Because the standard treatment for rotavirus
gastroenteritis is rehydration and supportive care, a specific microbiologic diagnostic is not
required in most cases. However, with prolonged diarrhea in complicated cases, in immune-
compromised hosts, when alternative diagnoses are considered, or when epidemiologic or
infection control date are needed, it may be desirable to establish rotavirus as the etiologic agent.
Definitively diagnosing rotavirus gastroenteritis may also to prevent unnecessary and potentially
harmful use of antibiotics.
Rotavirus can be detected by numerous techniques, including variety of commercial
antigen: assay, RT-PCR, electron microscopy, immune electron microscopy, polyacrylamide gel
electrophoresis (PAGE) for viral genomic RNA, and viral culture. Detection of viral antigen in
stool or rectal swabs, most commonly using enzyme-linked immunosorbent assay (ELISA) or
latex agglutination formats, forms the basic for practical, commercially available, and widely

18
used diagnostic kits. Latex agglutination is particularly suitable for use in areas with limited
resources, although a confirmatory technique is desirable to evaluate indeterminate result
because of the limited sensitivity of the test. Commercial antigenic assay primarily detect the
VP2 and VP6 proteins of the subviral double-layered particle and detect only group A
rotaviruses. Serotype-specific ELISAs, based on recognition of VP7 or VP4, allow
determination of serotype without the need to perform neutralization assay. Although there are
various technique for measuring serum, fecal, and salivary antibodies against rotavirus, the acute
and generally self-limited nature of rotavirus infection limits the usefulness of these techniques
for clinical decision making.
Multiplexed RT-PCR has become a major diagnostic technique used in epidemiologic
studies. RT-PCR allows determination of P and G types and permits finer definition of strain
differences. Real-time RT-PCR provides greater sensitivity and speed than conventional or
nested PCR diagnostis. DNA oligonucleotide microarray methods now being introduced offer
greater robustness to sequence drift (which can prevent PCR amplification if a primer binding
site is affected) and greater ability to distinguish a mixed infection from a single strain infection.
Both electron microscopi and PAGE can detect unusual strains of rotavirus (such as non
group A Rotaviruses) that might be missed by standard antigenic or nucleic acid-based assay.
Electron microscopy of stool specimens negatively stained with phosphotungsic acid is rapid
and, despite only moderate sensitivity, has high specificity because of the distinctive appearance
of rotavirus particles. Electrophoresis of simply prepared stool suspensions on polyacrylamide
gels followed by silver stainin for the pattern of 11 segments of genomic double- stranded RNA
allow both diagnosis and tracking of rotavirus strains in molecular epidemiologic investigations.
Rotavirus can be detected, although with relatively low sensitivity, by growth in cell culture.
Human rotavirus strains have proved more difficult to culture routinely that most animal
rotavirus strains but in many cases can be propagated in MA104 cells or primary green monkey
kidney cells grown in roller tubes with the addition of trypsin to the cell culture medium.

19
 Figure 4.

Rotavirus infection cannot be diagnosed on the basis of clinical presentation, even in

combination with stool examination and nonspecific tests have been developed. Findings
suggestive of rotavirus infection include a mildly febrile illness with vomiting and watery
diarrhea that is occurring in the winter months in temperate climates, especially in patients 6 to
20 months of age. The presence of more severe dehydration also is suggestive. In the initial
epidemiologic studies, electron microscopi was used for identification because of the large
number of particles present in stool (>10 10/g) and the characteristic appearance of rotavirus. This
technique largely has been replaced by enzyme immunoassay-based and latex agglutination tests,
for which kits are available commercially. Both tests have good sensitivity compared with
electron microscopy. One problem noted in the past was false positive result in neonatal stool
with certain ELISA kits (Aponte, Poncet, and Cohen. 1996). Inclusion of a rotavirus negative
capture antibody as a control in these kits could eliminate these false-positive reactions if it were
used. However, this is rarely done.
Rotavirus also can be grown in tissue culture, although the methods used for routine viral
cultures do not detect rotavirus. However, live virus can be detected readily, even in stool
specimens, by use of focus assays. The serotype of cultured strains and virus in stool can be

20
identified by use of monoclonal antibodies. DNA probes and particularly, RT-PCR have been
used effectively to identify genotypes as surrogates for serotype. Electrophoresis of extracted
RNA also can be identify rotavirus by its characteristic 11 segments and is used to define
electropherotypes. All these methods have proved useful as epidemiologic tools and in vaccine
studies. Identification of electropherotypes is especially useful for epidemiologic studies because
it allows identification of specific strains.
Rotavirus infection both symptomatic and asymptomatic, also can be identified by changes
in rotavirus antibody. ELISA assays are used most commonly to measure serum IgM, IgA and
IgG levels as well as stool and intestinal antibodies. Specific neutralizing titers also can be
measured foe each serotype of rotavirus by plaque reduction or focus reduction assays (Bridger
and Woode, 1975). One ELISA based antigen reduction neutralization assay has been found to
be better suited for the analyses of large numbers of specimens. Serologic detection of infection
is more difficult in the first months of life because of the presence of maternal antibodies.
Detection of rotavirus IgA, which does not cross the placenta, has been used as a marker for
previous infection in the first months of life.
Several studies have shown that breast-feeding protects against symptomatic rotavirus
infection.In one study, exclusive breast-feeding was found to be protection against severe
rotavirus diarrhea, but no overall protection was present during the first 2 years of life,
suggesting that breast-feeding simply postpones acquisition of rotavirus disease to an older age.
Similarly, cohort studies found that the highest incidence of rotavirus-associated with the age
when weaning from breast-feeding began. A study also found that breast-feeding was protective
against hospitalization for acute gastroenteritis caused by rotavirus in infants younger than 6
month.
Although breast-feeding alone could be the protective factor, other factors, such as
presence of maternal antibody and lack of opportunity for exposure, also could account for this
period of protection. Supporting the role of human milk in protection against rotavirus is a study
demonstrating that infants who received human milk with higher concentration of the
glycoprotein lactadherin were more likely to have asymptomatic rotavirus infection compared
with those receiving milk with lower concentration.

TREATMENT

21
 Treatment of rotavirus gastroenteritis is aimed largely at restoring the proper fluid balance
in dehydrated patients. Emphasis has shifted from intravenous rehydration to oral rehydration
with glucose-electrolyte solution. The glucose in the solution enhances sodium and, thereby,
water absorption the utility of this approach tine. Several studies have shown the utility of this
approach for treatment of rotavirus gastroenteritis. The solution accepted by the World Health
Organization contains 30 mEq/L of bicarbonate, which is similar to other oral rehydrating
solutions available commercially. Should oral rehydration not perforrmed efforts should be
administered intravenously.
Other experimental approaches to treatment are based on the success of passive oral
therapy in animals. Chronic rotavirus shedding has been treated successfully with human milk
that contained rotavirus antibody. Treatment and prophylaxis of normal children with
immunized cows also have been evaluated with success. The treatment of normal children with
one close human serum immunoglobulin given orally was reported to be effective in reducing the
mean duration of diarrhea, viral excretion, and hospital stay, and prophylaxis with formula
supplemented with bovine antibody decreased the number of days with rotavirus diarrhea. Trials
of bismuth subsalicylate also have been conducted with some reported success, as have trials
with probiotics.
Racecadotril (acetorphan), an enkephalinase inhibitor with antisecretory and antidiarrheal
properties that decreases intestinal hypersecretion but nor mortality by preventing the breakdown
of endogenous enkephalinase in the gastrointestinal track, has been shown to be effective in the
treatment of diarrhea in adults and children. In one study, oral treatment with Racecadotril
decreased stool output by 46 percent in boys 3 to 35 months of age with watery diarrhea. A
similar decrease was seen in boys with rotavirus infection.
Nitazoxanide, a drug licensed to treat Cryptosporidium parvum and Giardia lamblia
infections, was found to be effective in decreasing the time to resolution of rotavirus illness in
children hospitalized with severe rotavirus diarrhea to an average of 31 hours for the
nitazoxanide group compared with 75 hours in the placebo group. In addition, nitazoxanide, the
active metabolite of nitazoxanide, inhibited replication of rotavirus in cell culture. For this study,
only 50 children in Egypt were investigated; larger studies are planned.
Recommendations for treatment are summarized in a guideline from the Centers for
Disease Control and Prevention (CDC). As rotaviruse gastroenteritis is generally self-limited

22
and dehydration is the primary cause of morbidity, rehydration and restoration of electrolyte
balance are the primary therapies. Oral rehydration solutions (ORSs) are effective in treating
dehydration related to rotavirus gastroenteritis, even in the presence of moderate vomiting, and
are preferred over IV rehydration in cases of mild or moderate dehydration. The principle on
which these solutions are based is the solute-coupled cotransport of sodium by enterocytes,
which continues to operate even in the damaged gut. Effective solutes include glucose, amino
acids, and short oligopeptides.
In 2002, the World Health Organization revised the recommended standard oral
rehydration formula to a low osmolarity (245 mOsm/L) solution, which is associated with less
vomiting, lower stool output, and a reduced need for intravenous (IV) infusion. The low
osmolarity formulation is 75 Mm Na+, 20 Mm K+, 65 Mm Cl, 10 Mm citrate, and 75 Mm glucose
(see reference for acceptable variations). When oral dehydration cannot be maintained because
of severe vomiting, depressed level of consciousness, or intestinal ileus, and in cases of severe
dehydration (with loss of more than 9% of body weight), IV hydration with lactated Ringers
solution, normal saline, or similar solution is recommended. However, when the patient has
been resuscitated and is able to take oral fluids, oral rehydration should be instituted. Despite the
depressed disaccharidase levels associated with rotavirus gastroenteritis, it is recommended that
nursing infants continue to breastfeed during rehydration and that children resume a diet as soon
as they can tolerate feeding. The early reinstitution of an age-appropriate diet, avoiding foods
high in simple sugars, has nutritional benefits and shortens the duration of diarrhea by about half
a day.
Randomized controlled trials in developing countries have demonstrated that short courses
of zinc supplementation for 10 to 14 days can significantly decrease the prevalence of diarrheal
disease in the following 2 to 3 months (odds ratio = 0.66) and that zinc supplementation during
an episode of acute diarrhea can decrease duration of illness (15% reduced probability of
continued diarrhea on any given day). On this basis, the WHO has recommended zinc
supplementation (10-14 days of 10 mg/day for older infants) together with oral rehydration
therapy. Because the benefits of zinc supplementation in well-nourished populations have not
been established, this intervention is not currently recommended by the CDC for infants and
children in the United States.

23
 Racecadotril (no commercial preparations currently available in the United States) is an
enkephalinase inhibitor that inhibits intestinal hypersecretion and has been evaluated as an
adjunct to ORS in a placebo-controlled trial in Peru. Racecadotril combined with ORS cut total
stool output and the duration of diarrhea by about half compared with the use of ORS alone for
treatment of rotavirus gastroenteritis. Although these results are promising, the clinical role of
racecadotril is not yet clearly established.
Oral administration of immunoglobulins is not indicated for routine use, but may have a
role in treating chronic rotavirus diarrhea and may merit further evaluation for prophylaxis in
high-risk setting in which vaccination has not yet been shown to be efficacious. In case reports,
feeding human serum immune globulin to children with chronic rotavirus diarrhea has been
followed by resolution of diarrhea association with neonatal rotavirus infections
Because of complications including ileus and respiratory depression, antimotility agents
such as loperamide have no role in the treatment of childhood gastroenteritis. Bismuth
subsalicylate (Pepto-Bismol) has been shown to decrease the duration of diarrhea and the intake
of ORS in children with gastroenteritis, but the modest benefit observed and a theoretical
possibility of Reyes syndrome related to salicylate absorption argue against routine use of this
agent. Although its mechanism of action is unclear, probiotic treatment of childhood
gastroenteritis, including rotavirus gastroenteritis, by oral administration of lactobacillus appears
to shorten the duration of diarrhea about 0.7 days, based on a meta-analysis of randomized,
blinded, controlled trials.

PREVENTION AND CONTROL

Since virtually all children will have experienced rotavirus infection by the age of 3-5
years in both developing and develop countries, it is clear that the high standards of hygiene and
sanitation practiced in developed countries are not sufficient to prevent the spread of rotavirus
infections within of community. Thus, prophylaxis of severe rotavirus gastroenteritis by vaccine
remains as the only practical preventive measure. The first licensed rotavirus vaccine, a rhesus
monkey rotavirus-based tetravalent human reassortant vaccine (Rotashield), was withdrawn after
this live, oral vaccine was associated with the development of intestinal intussusceptions in
approximately 1:10.000 vaccine recipients in USA. Two new rotavirus vaccines, Rotarix, have
recently completed phase III clinical trials, each involving more than 60.000 infants. Both

24
vaccine were found to be safe when given to infants under 3 months of age and were >85 %
efficacious in preventing severe gastroenteritis due to rotavirus. Rotarix is a monovalent human
rotavirus vaccine of serotype GIP1A[8], whereas Rotateq is a pentavalent bovine-human
reassortant vaccine comprising types G1,G2,G3,G4 and P[8]. Update disease burden estimates
and economic justification will be needed wherever vaccine introduction is considered. Further
confirmation of the safety profile of either vaccine will depend on post-licensure evaluation.
Assessment of the ability of each vaccine to provide protection against and increasingly diverse
population of rotavirus strains will require continuous global strain surveillance. Rotavirus does
not produce more severe disease in HIV-infected infants, so use of live-reassortant rotaviruses in
populations with a high prevalence of HIV should not pose a risk.

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