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Rotavirus

Queensland Health Guidelines for Public Health Units

Revision History

VersionDateChanges
1.0 February 2012

Full revision of guideline

2.0 June 2017

Limited revision of ‘Preventative measures’
in line with updated immunisation recommendations

3.0 August 2018 Limited revision - case definition update

Infectious Agent

The infectious agent is rotavirus (most commonly Group A), a member of the Reoviridae family

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Notification Criteria

Confirmed case

A confirmed case requires either:

1. laboratory definitive evidence

OR

2. laboratory suggestive evidence AND epidemiological evidence.

Laboratory definitive evidence

Detection of wild-type rotavirus by nucleic acid testing*

Laboratory suggestive evidence

1. Detection of rotavirus by antigen assay

OR

2. Detection of rotavirus by nucleic acid testing

OR

3. Detection of rotavirus by electron microscopy

OR

4. Isolation of rotavirus

Epidemiological evidence

The case is older than 8 months of age

OR

The case has not been vaccinated in the 4 weeks prior to testing.

Probable case

A probable case requires laboratory suggestive evidence only.

*detection of rotavirus by nucleic acid testing that does not distinguish between wild-type and vaccine-related virus is suggestive laboratory evidence

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Notification Procedure

Pathology Laboratories:
To notify on confirmation of laboratory definitive and /or suggestive evidence by usual means.

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Laboratory Aspects

Testing for rotavirus in faecal specimens must be specifically requested.

Testing is most commonly conducted using antigen assay or PCR offered by Pathology Queensland Central Laboratory, Forensic and Scientific Services (FSS) and private laboratories.

Viral culture does not have a role in diagnosis of acute disease and electron microscopy is not routinely performed.

Reports of issues with false positives from antigen assays have been under investigation since September 2011.

Refer to Pathology Queensland test list for specimen collection, storage, and transport advice. Advice as of June 2018 is:

  • Faeces specimens for antigen assay require several mls of faeces and must be tested within 3 days of collection and stored at 4°C. If this is not possible, specimens must be frozen at -20°C. Faeces contaminated with water, urine or fixatives are not suitable.
  • Faeces specimens for PCR testing require 1 ml or 1 g of faeces. Specimens should be refrigerated immediately and transported as soon as possible at 4°C.

The Australian Rotavirus Surveillance Program, together with collaborating laboratories Australia-wide, conducts a laboratory based rotavirus surveillance program. The program began in 1999 and publishes annual reports describing the genotypes of rotavirus strains responsible for the hospitalisation of children with acute gastroenteritis. In Queensland, collaborating laboratories in 2015 were FSS and Pathology Queensland (Central Laboratory plus Townsville).

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Reporting to NOCS

Report confirmed and probable cases.

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Objectives of Surveillance

  1. To monitor the effects of vaccination on burden of disease and serotype/genotype distribution.
  2. To identify outbreaks/issues of public health concern so that appropriate public health action can be taken.

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Public Health Significance and Occurrence

Rotavirus gastroenteritis causes highly infectious diarrhoea, especially in infants and young children with a peak incidence among children between 6 months and 2 years of age.  Worldwide, rotavirus is the most common cause of severe diarrhoeal disease in infants and young children and is estimated to be responsible for more than half a million deaths each year, with the vast majority occurring in low-income countries in Africa and Asia.

In Australia, prior to the national introduction of rotavirus vaccination, it was estimated that rotavirus accounted for around half of the 20,000 hospitalisations for acute gastroenteritis of any cause in the under 5 years age group.

In addition, an estimated 115,000 children under 5 years visited a GP and 22,000 children required an emergency department visit for rotavirus infection every year in Australia. On average, one death was recorded as due to rotavirus each year in Australia.

Indigenous Australian infants and children are 3—5 times more likely than other Australian infants and children to be hospitalised with rotavirus gastroenteritis. They are often admitted at a younger age and stay more than twice as long in hospital compared with other infants.

In temperate climates (e.g. Brisbane), there tends to be a seasonal peak of rotavirus infection in mid to late winter. There is no consistent seasonal pattern for rotavirus infection in northern Australia.

For infants, vaccination reduces the risk of developing severe rotavirus gastroenteritis by 85—100% and any rotavirus gastroenteritis by around 70% over the following 1—2 years.

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Clinical Features

The spectrum of rotavirus illness ranges from asymptomatic infection to mild, watery diarrhoea of limited duration, to severe dehydrating diarrhoea with vomiting, fever, electrolyte imbalance, shock and death. Illness can begin abruptly with vomiting often preceding the onset of diarrhoea which usually lasts from 2—5 days.

Up to one third of patients have a temperature of >39oC in the first few days. Symptoms generally resolve in 3—7 days.

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Reservoir

Humans: Human infection due to animal rotaviruses appears uncommon.

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Mode of Transmission

Rotaviruses are highly contagious and are transmitted via the faecal-oral route, via close person-to-person spread and fomites. Rotavirus infection is probably also spread by ingestion of contaminated food or water and by respiratory droplets.

The virus survives for long periods (hours to a week or more) on hard services, in contaminated water and on hands and is relatively resistant to commonly used disinfectants. It is inactivated by chlorine.

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Incubation Period

Incubation period is 24—72 hours.

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Period of Communicability

Can commence prior to symptoms, but maximal during the acute stage, and later while virus shedding continues (generally up to 8 days). Excretion of virus for 30 days or more has been reported in immunocompromised patients. Virus excretion can occur in asymptomatic individuals.

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Susceptibility and Resistance

Susceptibility is greatest between 6—24 months of age. By age 3, most individuals have acquired rotavirus antibodies. After a single natural infection, 40% of children are protected against any subsequent infection with rotavirus, 75% are protected against diarrhoea from a subsequent rotavirus infection, and 88% are protected against severe diarrhoea.

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Management

Cases:
Clinical management and supportive therapy as clinically indicated.

Investigation:
Sporadic Cases: Investigation not routinely required.
Outbreaks: Outbreaks in child care facilities or other institutions should be investigated and managed in the same way as other outbreaks of gastroenteritis in institutions.

Restriction:
Exclude the case from childcare, school or work until there has not been a loose bowel motion for 24 hours. Exclude all cases who are food handlers or carers of patients, children or the elderly until they have not had any diarrhoea or vomiting for 48 hours.

Counselling:
In an outbreak situation,highlight preventative measures.

Contacts:

Contact Tracing:
Not routinely

If contact tracing occurs, contacts should be advised of the nature of the infection, its mode of transmisison, the importance of hand washing and good hygiene practices.

Other control measures:

  • Personal hygiene measures as per other gastrointestinal infections.
  • Environmental cleaning with chlorine.

Community outbreaks/epidemics:

  • Hygiene measures.
  • Promotion of vaccination in eligible infants.

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Preventive measures

Rotavirus vaccination was included in the National Immunisation Program from 1 July 2007. Two oral rotavirus vaccines are currently registered in Australia – Rotarix and RotaTeq. Immunisation against rotavirus is recommended for infants as part of the National Immunisation Program Schedule. For current recommendations regarding the Queensland immunisation schedule, refer to the Queensland Health Immunisation Program web page. For vaccine specific recommendations regarding strict timeframes and age restrictions for the administration of these vaccines refer to the current edition of the Australian Immunisation Handbook.

In Australia, two post-marketing studies have found an apparent four-fold increased risk of intussusception in infants within one week of being given the first dose of either RotaTeq or Rotarix. It is currently unclear whether this represents a true increase in overall risk, or an early increase in risk in infants which is compensated for by a subsequent decrease in risk leading to fewer cases of intussusception in older children. Longer term studies are required to clarify this.  Based on the established benefits of rotavirus vaccination and the rare occurrence of intussusception, both the World Health Organization and the Australian Technical Advisory Group on Immunisation have recommended the continued use of rotavirus vaccine for infants. However, rotavirus vaccine should not be given to an infant who has had a confirmed intussusception because there may be an increased risk of the condition recurring.

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Summary

If an outbreak investigation is conducted, prepare a summary report for the Communicable Diseases Branch Queensland Health, on request.

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References

Heymann, D. (Ed).  2008.  Control of Communicable Diseases Manual, 19th edition. American Public Health Association: Washington.

National Centre for Immunisation Research and Surveillance of Vaccine Preventable Diseases (NCIRS), 2013. Rotavirus Vaccines for Australian Children: Information for Immunisation Providers. Available at: http://www.ncirs.edu.au/assets/provider_resources/fact-sheets/rotavirus-fact-sheet.pdf

Australian Technical Advisory Group on Immunisation (ATAGI). The Australian immunisation handbook 10th ed (2017 update). Canberra: Australian Government Department of Health, 2017.

Public Health Laboratory Network, 2006.  Laboratory case definitions: Diarrhoea caused by rotavirus laboratory case definition summary.  Available at: http://www.health.gov.au/internet/wcms/publishing.nsf/Content/cda-phlncd-rotavirus

Kirkwood, C. et al., 2010. Australian Rotavirus Surveillance Program: Annual report, 2009/2010. CDI 34: 4.  Available at:

http://www.health.gov.au/internet/main/publishing.nsf/content/cda-pubs-annlrpt-rotavar.htm

Sattar SA, Lloyd-Evans N, Springthorpe VS, Nair RC., 1986. Institutional outbreaks of rotavirus diarrhoea: potential role of fomites and environmental surfaces as vehicles for virus transmission. J. Hyg. (Lond). 96:277-89.

Ansari, S. et al., 1988. Rotavirus Survival on Human Hands and Transfer of Infectious Virus to Animate and Nonporous Inanimate Surfaces. Journal of Clinical Microbiology, Vol. 26: 8: 1513-1518. Available at:

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC266652/pdf/jcm00080-0089.pdf

Galati JC, Harsley S, Richmond P, Carlin JB. The burden of rotavirus-related illness among young children on the Australian health care system. Australian & New Zealand Journal of Public Health 2006;30:416-21.

Australian Government, 2010. Vaccine Preventable Diseases in Australia, 2005 to 2007. Available at http://www.health.gov.au/internet/publications/publishing.nsf/Content/cda-cdi34suppl.htm~cda-cdi34suppl-3-vpd.htm~cda-cdi34suppl-3-vpd13.htm

World Health Organization, 2011. Rotavirus. Available athttp://www.who.int/nuvi/rotavirus/en/.

Therapeutic Goods Administration, 2011. Rotavirus vaccination and risk of intussusception: a report of TGA's investigation of a possible safety signal. Available at http://www.tga.gov.au/safety/alerts-medicine-rotavirus-110225.htm

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Footnotes

Rotavirus is not nationally notifiable. This case definition is from the Public Health Laboratory Network.

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Last updated: 1 June 2017