Endemic Norovirus Infections in Children, Ho Chi Minh City, Vietnam, 2009–2010

Phan Vu Tra My, Corinne Thompson, Hoang Le Phuc, Pham Thi Ngoc Tuyet, Ha Vinh, Nguyen Van Minh Hoang, Pham Van Minh, Nguyen Thanh Vinh, Cao Thu Thuy, Tran Thi Thu Nga, Nguyen Thi Thu Hau, James Campbell, Nguyen Tran Chinh, Tang Chi Thuong, Ha Manh Tuan, Jeremy Farrar, and Stephen Baker

Author affiliations: Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam (P.V. Tra My, C. Thompson, N.V.M. Hoang, P.V. Minh, N.T. Vinh, C.T. Thuy, T.T.T. Nga, J. Campbell, J. Farrar, S. Baker); Oxford University, Oxford, UK (C. Thompson, J. Campbell, J. Farrar, S. Baker); Children’s Hospital 1, Ho Chi Minh City (H.L. Phuc, T.C. Thuong); Children’s Hospital 2, Ho Chi Minh City (P.T.N. Tuyet, N.T.T. Hau, H.M. Tuan); Hospital for Tropical Diseases, Ho Chi Minh City (H. Vinh, N.T. Chinh); The London School of Hygiene and Tropical Medicine, London, UK (S. Baker)

Abstract

We performed a case–control investigation to identify risk factors for norovirus infections among children in Vietnam. Of samples from 1,419 children who had diarrhea and 609 who were asymptomatic, 20.6% and 2.8%, respectively, were norovirus positive. Risk factors included residential crowding and symptomatic contacts, indicating person-to-person transmission of norovirus.

Norovirus (NoV) is a leading cause of acute gastroenteritis in children <5 a="" age="" href="http://wwwnc.cdc.gov/eid/article/19/6/11-1862_article.htm?s_cid=eid-gDev-email#r1" of="" title="1" years="">1
). The epidemiology of NoV in industrialized countries has been intensively investigated, yet the contribution of this pathogen to the effects of diarrheal disease in low- and middle–income countries is not well characterized (1,2). Gaining insight into the epidemiology of NoV infections of children in such countries is essential for disease control, particularly considering that several vaccine candidates are in advanced-stage clinical trials (3). To address the lack of data on risk factors for endemic NoV infections in low-income countries, we conducted a prospective case–control study among hospitalized children in a major urban location in southern Vietnam.

The Study

This study was conducted in 3 hospitals (Children’s Hospital 1, Children’s Hospital 2, and the Hospital for Tropical Diseases) in Ho Chi Minh City, Vietnam, during May 2009–December 2010. Written informed consent from a parent or legal guardian was mandatory for participation. Children <5 2009="" 2010.="" 2010="" 24-hour="" 3="" a="" acute="" admission="" age="" and="" antimicrobial="" attending="" before="" bloody="" checks="" chi="" children="" city="" clinics="" collect="" conditions="" control="" criteria="" data="" days="" demographic="" departments="" diarrhea="" did="" drug="" drugs="" during="" ecember="" enrolled="" for="" gastroenteritis.="" gastroenterology="" given="" group="" had="" have="" health="" ho="" hospitalization="" in="" inpatient="" invited="" loose="" march="" may="" met="" minh="" no="" not="" nutrition="" of="" on="" or="" outpatient="" p="" participate="" period="" preceding="" pril="" received="" resided="" routine="" same="" stool="" stools="" the="" this="" to="" treatment="" unrelated="" we="" weeks.="" were="" who="" within="" years=""> Stool specimens were collected from case-patients on the day of admission (n = 1,419) and from control participants while they were attending the clinic (n = 609). All stool samples were cultured by using classic microbiologic methods to detect Shigella, Salmonella, Campylobacter, and Yersinia spp. and were microscopically examined for Entamoeba, Cryptosporidium, and Giardia spp. Methods are described in the Technical Appendix. Conventional reverse transcription PCR was performed on RNA extracted from stool samples to detect rotavirus (4) and NoV genogroups I (GI) and II (GII) (5), followed by direct sequencing of the amplicons for genotyping.
After rotavirus (46.6%; 661/1,419), NoV was the second most common pathogen detected in symptomatic case-patients (20.6%; 293/1,419); diarrheal bacteria and parasites were cumulatively found in 14.5% (Technical Appendix

[PDF - 183 KB - 2 pages]). The prevalence of NoV was higher than in a pooled international estimate (1) and than in previous studies performed in Ho Chi Minh City (6–8), yet was lower than that found in a study conducted in northern Vietnam (9). The frequency of NoV detected in control participants was 2.8% (17/609), similar to a pooled international estimate (1). The majority of NoV-positive case-patients experienced nonbloody, nonmucoid watery diarrhea, vomiting, and fever. These symptoms were comparable to those in previous studies of diarrheal infections in children in Vietnam (7,9).
NoV was detected throughout the study period (Technical Appendix

[PDF - 183 KB - 2 pages] Figure). There was a positive linear correlation between NoV infections and monthly rainfall (R = 0.550, p = 0.029), but no similar correlation with temperature (range 22.1°C–37.8°C) (R = 0.308, p = 0.330). This association of NoV infections with the tropical rainy season may reflect differential transmission between different climatic regions because NoV infections are typically associated with the winter season in industrialized countries in temperate regions (10).
GII NoV was detected in 239 (99.1%) of 241 and 11 (73.3%) of 15 NoV-positive stool samples from the symptomatic and asymptomatic enrollees, respectively. The remaining children were infected with NoV GI (GI.3, GI.4, GI.5); 1 enrolled case-patient was infected with 2 genotypes: NoV GI.3 and GII.4. Of the GII strains, GII.4 was the most prevalent genotype, comprising 201 (84.1%) of the 239 samples. The next most prevalent was GII.3: 24 (10.0%) were identified in the symptomatic and asymptomatic groups. Other GII genotypes (GII.2, GII.6, GII.7, GII.9, GII.12, and GII.13) were found in <3 nov-positive="" of="" p="" samples.=""> Socioeconomic and behavioral data were obtained from all enrollees by using a questionnaire and analyzed by using Stata Version v9.2 (StataCorp LP, www.stata.com) (Table 1). We used χ² and Fisher exact tests to compare proportions between groups and Mann-Whitney U tests for nonparametric data. Univariate analyses were performed to assess factors associated with symptomatic NoV infections. Factors found to be significantly associated with infection in the univariate analysis, in addition to a-priori factors of age, sex, and income level, were then included in a multivariate logistic regression model to simultaneously control for confounding effects. Two-sided p values ≤0.05 were considered significant throughout (Table 2).
NoV infections are commonly associated with outbreaks in enclosed environments (2), yet we found attendance in daycare centers and nursery schools was not common; the majority of children remained at home during the day. However, several factors were significantly and independently associated with symptomatic NoV infections. Demographic risk factors included younger age (in months) (adjusted odds ratio [aOR] 0.96, 95% CI 0.94–0.98, p<0 .001="" 0.001="" 0.1="" 0.22="" 1.0="" 1.4="" 1.70="" 10.4="" 2.18="" 26.14="" 3.1="" 4.99="" 95="" a="" added="" also="" and="" aor="" association="" be="" before="" boiling="" bottled="" can="" capabilities="" children="" ci="" consistent="" consuming="" consumption="" contact="" containing="" contamination="" correlate="" crowding="" diarrheal="" did="" drinking="" during="" factor="" fecal="" filtering="" finding="" food="" for="" found="" from="" further="" greatest="" had="" house="" household="" however="" href="http://wwwnc.cdc.gov/eid/article/19/6/11-1862_article.htm?s_cid=eid-gDev-email#r11" in="" income.="" infancy="" infection.="" infections="" investigations="" is="" living="" location="" markets="" may="" municipal="" nature="" not.="" not="" nov="" of="" or="" outbreaks="" outdoor="" outside="" p="" period="" person-to-person="" person="" pipeline="" poor="" possibly="" predominant="" previous="" protecting="" protective="" purchased="" quality.="" rather="" recently="" regularly="" reported="" residence="" result="" risk="" showing="" significant="" sporadic="" sterilizing="" suggests="" sunlight="" symptomatic="" than="" that="" the="" they="" this="" those="" title="11" toilets.="" toilets="" transmission="" unexpected="" unpredictably="" use="" was="" water="" we="" where="" which="" who="" with="">11

–14). This study has several limitations. First, passive case detection limits generalizability because health care–seeking behavior may depend on disease severity and income in this setting. Second, the control participants may not be entirely representative of the population from which the case-patients arose because a large proportion of the control participants were visiting the hospital for nutritional advice, which may have an effect on diarrheal disease risk (15). Yet, a limited sensitivity analysis comparing NoV-positive case-patients to NoV-negative control participants and NoV-negative case-patients to NoV-negative control participants demonstrated several differences in risk factors, suggesting that the identified risk factors are associated with NoV rather than health care–seeking behavior (Appendix Table 2).