Hospital-based Surveillance of Rotavirus Gastroenteritis
in Latin America
The Latin America Rotavirus Vaccine Study Group Presented by Miguel O’Ryan
ProfessorInstitute of Biomedical Sciences
University of Chile
• Background– RV-associated disease burden data are limited
•Opportunity– Set up of phase III RV vaccine trial
•Objective– Describe disease burden of RV GE in Latin America
•Methods– Prospective, multi-center, hospital-based study in 11
countries– Inclusion Criteria
• Children <3 years • Treated at hospital site for Gastroenteritis
Study Sites in Latin America
Ciudad de México(MX)
Durango (MX)
Belem (BZ)
Santo Domingo (DR)
Léon (NI)
Tegucigalpa (HO)
Panamá (PA)
Viña del Mar (CH)Concepción-Talcahuano
Chiriqui (PA)
Mendoza (AG)
Valencia (VE)
Cali (CO)
Estado de México (MX)
Morelos (MX)
Study Duration by Country- limitation of study -
Country Nov-02 Dec-02 Jan-03 Feb-03 Mar-03 Apr-03 May-03 Jun-03 Jul-03 Aug-03 Sep-03
VenezuelaBrazilCosta RicaMexico PanamaChileDominican RepublicHondurasArgentinaNicaraguaColombia
Range: 50-220 days; Median: 158 days
Results
Baseline DataDiarrhea episodes 8,031
Completed questionnaires and stool samples
81% (6,521)
Hospitalized patients (inpatients) 78%
Median age 1 year
Male : Female ratio 1.4 : 1
Rotavirus positive/tested (%) 3,122/6,361 (49%)
Hospitalized patients (inpatients) 2,421 (78%)
Male : Female ratio 1.4 : 1
0%
20%
40%
60%
80%
Dec Jan Feb Mar Apr May Jun
% o
f po
sitiv
e RV
sam
ples
Mexico (n=1154) / Range 10% - 79%
0%
20%
40%
60%
80%
Dec Jan Feb Mar Apr May Jun
% of
pos
itive
RV
sam
ples
Venezuela (n=301) / Range 8% - 7 8%
0%
20%
40%
60%
80%
Dec Jan Feb Mar Apr May Jun
% o
f po
sitiv
e RV
sam
ples
Costa Rica (n=635) / Range 11% - 63%
0%
20%
40%
60%
80%
Dec Jan Feb Mar Apr May Jun
% o
f po
sitiv
e R
V sa
mpl
es
Dom Rep (n=395) / Range 35% - 80%
Proportion of RV Positive by Month
0
20
40
60
80
100
0 6 12 18 24 30
Age in months
Perc
ent
Overall Cumulative Age Distribution of RV+ Children (%)
12 months 54% 24 months 90%6 months 18%
0
20
40
60
80
100C
hile
Cos
ta R
ica
Pan
ama
Bra
zil
Nic
arag
ua
Arg
entin
a
Mex
ico
Hon
dura
s
Dom
inic
an
Vene
zuel
a
Ove
rall
Cumulative age distribution of rotavirus positive children at 12 months of age, by country
54%
Median delay between RV GE onset andhospital adm ission 2 days
Received oral hydration (single or combinationtherapy) 52%
Received antibiotic therapy 27%
Results
Treatment RV+ GE• Before coming to hospital site
Received oral-intravenous hydration (single or combination therapy) 69-77%
Received antibiotic therapy 24%
• At hospital site
0
1
2
3
4
Overa
llCol
ombi
aCos
ta R
icaMex
icoHon
dura
sPan
ama
Argen
tina
Chile
Nicara
gua
Venez
uela
Brazil
Median Duration of Hospitalization Due to RV Gastroenteritis
(2 days)
Outcome of Hospitalized RV+ Cases
Fully recovered at time of discharge 96%
Sequelae at time of discharge 4%
Died (2 patients among 3,122 RV+ children) <1%
1240 RV Strains Serotyped (~ 110/country)
Country G1 G2 G3 G4 G9 UntypOverall 51% 1% 10% 18% 3% 17%Argentina 96% 0% 0% 0% 0% 4%Brazil 57% 1% 0% 2% 8% 31%Chile 21% 1% 0% 66% 0% 12%Colombia 88% 0% 0% 0% 0% 13%Costa Rica 30% 0% 68% 2% 0% 0%Dominican 46% 2% 21% 0% 0% 31%Honduras 100% 0% 0% 0% 0% 0%Mexico 48% 3% 5% 11% 9% 23%Nicaragua 28% 3% 33% 20% 0% 16%Panama 89% 4% 7% 0% 0% 0%Venezuela 42% 0% 13% 19% 0% 26%
Household Costs of RV Gastroenteritis
Collaboration Emory University
• Obtained information family expenditures
• Caregiver cost questionnaire (subset of cases)
– payments for medical treatment
– out of pocket expenses (travel, additional supplies)
– time lost from work
– qualitative impact on households
0% 10% 20% 30% 40% 50% 60% 70%
Overall
Chile
Venezuela
Honduras
Brazil
Costa Rica
Argentina
Mexico
Panama
Dominican
Nicaragua
Colombia
Proportion of Parents Who Took Paid Time Off (overall 40%)
0 5 10 15 20 25 30
Overall
Colombia
Costa Rica
Honduras
Panama
Dominican
Mexico
Venezuela
Brazil
Argentina
Chile
Nicaragua
Hours Lost From Paid Work (Median 12 hours)
hours
3%
13%
24%
33%
51%
0% 10% 20% 30% 40% 50% 60%
Sold assets
Asked for donation
Used Savings
Cut Expenses
Borrowed
Source of Money to Pay for Illness Associated Expenses
Impacto de Infección por Rotavirus en LatinoaméricaO’Ryan M, Pérez-Schael et al. Ped Infect Dis J 2001; 20:685-93
Santiago:
Sótero del RíoBs. Aires:
Ricardo Gutiérrez
Valencia:
Jorge Lizarraga
Visitas Médicas: Número de deposiciones:
Lugar Totales Diarrea aguda Obtenidas Rota +
Argentina 116,596 4,375 (3.8%) 1,133 (26%) 438 (39%)
Chile 123,320 6,599 (5.4%) 1,739 (26%) 585 (34%)
Venezuela 36,787 3,370 (9.2%) 2,929 (87%) 848 (29%)
Impacto de la diarrea aguda total y por rotavirusen visitas médicas
Niños < 36 meses de edad, período estudio 48 meses
Hospitalizaciones: Número de deposiciones:
Lugar Totales Diarrea aguda Obtenidas Rota +
Argentina 2.550 56 (2.2%) 34(61%) 24 (71%)
Chile 4.773 283(5.9%) 276 (98%) 130 (47%)
Venezuela 8076 1071(13%) 946 (88%) 355 (38%)
Impacto de la diarrea aguda total y por rotavirusen hospitalizaciones
Impacto de Enfermedad Por Rotavirus ExtrapoladaO’Ryan M, Pérez-Schael et al. Ped Infect Dis J 2001; 20:685-93
Visitas Médicas HospitalizacionesPaís Totales Pob < 3 años Totales Pob < 3 años
Argentina 106.000 1/20 20.875 1:100
Chile 57.761 1/22 8.800 1:136
Venezuela 96.000 1/18 31.000 1:55
Conclusion-Summary
• Rotavirus causes a highly significant proportion of diarrhea cases among children < 3 years of age in Latin America:
– 40-50% of cases requiring hospitalization– 30-40% of cases requiring ER visit
• Seasonal variations and age prevalence variations among countries.– Small proportion (<20%) occurring in < 6 months of age.
• Marked overuse of antimicrobials for rotavirus diarrhea, significant need for IV rehydration.
• Low mortality as expected for a prospective surveillance study• Different serotype patterns across countries within the same season
– Low circulation of G2 types during the period – Emerging G9 in certain countries
• Households in Latin America are economically affected by RV GE – additional point to consider outside “health care perspective”
