Burden of Rotavirus Gastroenteritis in Children in Middle East and North Africa

1. Introduction • Rotavirus gastroenteritis (RVGE) is the most common cause of severe childhood diarrhea worldwide and of diarrhea mortality in developing countries.1 • About 95% of children aged between 3 and 5 years are affected by rotavirus infection.2 • Each year worldwide, rotavirus causes about 111 million episodes of gastroenteritis requiring home care only, 25 million office visits, 2 million hospitalizations,3 and 527,000 deaths among children ≤ 5 years old.4 • Among the most prevalent rotavirus sero-groups, viruses carrying either G1, G2, G3, G4, G9 and P[4] or P[8] are the most common causes of rotavirus disease in humans. • Objective • To estimate the burden of RVGE among children ≤ 5 years old in the Middle East, North Africa, and Turkey for its regional proximity. • Methods • A systematic literature search was conducted in major databases (PubMed, the Center for Disease Control rotavirus global surveillance,5 and the WHO6) on epidemiologic and economic burden of rotavirus among children ≤ 5 years of age. • The search was limited to studies published in the last ten years from the Middle East (Bahrain, Iran, Iraq, Israel Jordan, Kuwait, Oman, Qatar, Saudi Arabia, Syria, UAE, Yemen), North Africa (Algeria, Egypt, Libya, Morocco, Tunisia), and Turkey. • Search terms included: rotavirus, outcome, mortality, death, incidence, prevalence, serotype, strain, cost, economic, burden, and resource use. • Data was extracted and compared for each country. Figures are reported as originally described in the source articles. • When several studies were published for a single country, a pooled average of the proportion of RVGE among cases of acute gastroenteritis was calculated and reported. • Figures for the distribution of rotavirus genotype combinations were taken from the most recent available data. Where two studies from the same year and the same country showed a similar distribution, a weighted average across the studies was calculated to present as one figure. Burden of Rotavirus Gastroenteritis in the Pediatric Population of the Middle East and North AfricaIslaOgilvie PhD,1 Hanane Khoury PhD,1 Antoine C. El Khoury PhD,2 Yinghui Duan MS,2 Mireille M. Goetghebeur M PhD11.BioMedCom Consultants inc, Montreal, Quebec, Canada; 2.Merck & Co, West Point, PA, USA Results • 1. Studies included • 44 citations were identified that contained relevant RVGE data. • 3. Rotavirus genotype combinations • G1P[8] was most prevalent in 8 countries (23%–56% of all genotyped samples);8,16,24,31,32,36-38 • G2P[4] was most prevalent in 4 countries (26%–48%).12,19,22 • G9P[8]7-9,12,13,16,19,23,24,31-33,37-40 and G4P[8]12,16,18,24,32,37 were also frequently detected in many countries. • Rotavirus genotype distribution evolved over time (data available from 5 countries); the distribution pattern varied between countries. • G1P[4] , a new reassorted rotavirus strain emerged in Tunisia during 1998-1999.13 • 2. RVGE proportion and seasonality • RVGE accounted for 16-61% of all annual cases of acute gastroenteritis. Saudi Arabia,7-11 Tunisia,12-18 and Egypt12,19-21 had the lowest proportion of RVGE, while Syria,12 Oman,12,22,23 and Kuwait24 had the highest RVGE proportion. • Peak RVGE season is in the winter,8,14,17,18,20,22,25-35 except in Egypt where rotavirus infection peaks in July to November.20,25 “Other” includes the proportion of rare and mixed genotype combinations, and non- or partially-typable serotypes • 4. Morbidity and mortality associated with RVGE • Between 37% and 90% of children with RVGE had severe disease on the Vesikari scale.33,35,41 • Rotavirus disease severity was significantly higher than non-RVGE.31 • Annual mortality rates ranged from 0 (Bahrain, Israel) to 112 (Iraq) per 100,000 children < 5 years of age.42 • When the overall pediatric population (< 5 years) from all countries was considered,43 the average mortality rate was estimated at 39 per 100,000 children < 5 years of age per year. • Over time, the proportion of RVGE among acute gastroenteritis cases increased in Egypt (2000 to 2007)12,20 and Iran (2003-2004 to 2006-2007),26,29 and decreased in Saudi Arabia (1995-1996 to 2002-2003).9,11 • 5. Resource use and costs associated with RVGE • RVGE-related hospitalization rates were generally higher than non-RVGE (RVGE 14%-57%20,21,35,44,45 versus 14.4%-28.4% for non-RVGE35,44). • The average duration of hospital stay due to RVGE varied between 3 and 5.5 days.22,35,36,46 • Hospital stay increased with younger age, and was significantly longer for RVGE versus non-RVGE5,46 • The majority of children hospitalized for RVGE required intravenous rehydration.22,31,33,41,46,47 • The annual cost of hospitalization due to RVGE was estimated at 2008 $1.8 million and $4.6 million in Oman and Israel, respectively.22,36 *Dates refer to when studies were conducted • References • Widdowson M-A, Steele D, Vojdani J, Wecker J, Parashar UD. Global rotavirus surveillance: preparing for the introduction of rotavirus vaccines. J Infect Dis. 2009;200(Suppl1):S1-S8. • Parashar UD, Bresee JS, Gentsch JR, Glass RI. Rotavirus. 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Am J Infect Control. 2009;37(6):465-9. • Youssef M, Shurman A, Bougnoux M, Rawashdeh M, Bretagne S, Strockbine N. Bacterial, viral and parasitic enteric pathogens associated with acute diarrhea in hospitalized children from North Jordan. FEMS Immunol Med Microbiol. 2000;28(3):257-63. • Conclusions • RVGE is a common disease resulting in significant morbidity, mortality, and costs in the Middle East and North Africa. • Study limitations that restricted comparability of data across countries are: limited availability of recent serotype information in some countries and wide variation in time frames; variations in study setting and design. In addition, limited data availability on RVGE mortality, morbidity, and economic burden restricted the evaluation of RVGE global burden for the region. • A vaccine with broad and consistent serotype coverage would be important to help decrease the burden of RVGE in the region.