Infection (1980) 1, 327-331
acquired rotavirus infection Who is at risk?
W. D. Cubitt* and H. Holzel?
*Public Health Laboratory and Department of Microbiology, Central Middlesex Hospital, Park Royal, London NW10 7NS, U.K. Summary: An outbreak of rotavirus infection is described in which equal numbers of young female patients (30-60 years) and older individuals ( >60 years) were at risk. Among the patients illness was confined to the older age group, but three young members of the staff also acquired infection. Severe diarrhoea requiring intravenous rehydration occurred in several individuals, and high antibody levels to rotavirus were demonstrated in affected patients. Screening procedures of patients and staff revealed campylobacter in three individuals. Our findings support our previous suggestion that rotavirus infection in older females in closed communities is not uncommon, and emphasises the need for bacteriological, and virological investigations to be performed in parallel. Introduction It is now generally accepted that rotavirus infections are a major cause of acute gastroenteritis in infants and young children. Neonatal rotavirus infections have been reported to be common in obstetric hospitals (Cameron, Bishop, Veenstra, Barnes, Holmes & Ruck, 1978; Chrystie, Totterdell & Banatvala, 1978) and nosocomial infections may account for up to 30 per cent of the casesstudied in the 6 month to 2 year age group (Flewett, Bryden, Davies & Morris, 1975; Middleton, Syzmanski & Petric, 1977; Ryder, McGowan, Hatch & Palmer, 1977.) Adult infection was first proven in 1974 by a volunteer study, (Middleton, Syzmanski, Abbott, Bortolussi & Hamilton, 1974), and since that time a number of casesof rotavirus infections in adults have been reported. These have usually involved parents, nursing or medical staff (Tufvesson, Johnsson & Persson, 1977; Meurman & Lane, 1977; Von Bonsdorff, Hovi, Makela & Morttinen, 1978). Reports of hospital acquired outbreaks however have only recently been recorded (Cubitt & Holzel, 1980; Holzel, Cubitt, McSwiggan, Sanderson & Church, 1980). In these outbreaks contact with children could definitely be excluded, and there was evidence for transmission of virus from person to person within the wards. In each episode all the affected patients were elderly (~64 years) suggesting that this age group is particularly at risk. A recent paper from Scandinavia describes an outbreak in a nursing home for the elderly (Halvosrud & Orstavik, 1980) and supports this view. This report describes a more serious episode involving patients and staff on two TPresent address : Department London SE5 9RS, U.K. 0195-670I/80/040327
medical wards of a district general hospital. Symptoms were confined to patients of the older age group (61-90 years) although an equal number of young patients (30-60 years) was also at risk. An important feature of this outbreak was the severity of diarrhoea which required intravenous rehydration and resulted in
prolonged hospital stay. Clinical setting The outbreak took place in a district general hospital in North West London. Female patients on two wards became ill. These wards (A & B) were of the Nightingale design and each contained 24 beds and two isolation cubicles. In ward A only medical caseswere admitted, whereas on ward B, patients could be grouped into three distinct categories: longstay medical cases (61-90 years), short stay patients admitted for minor gynaecological surgery (30-60 years), and children with gastroenteritis, who were admitted to the isolation cubicles. During the day each ward was staffed by its own team of nurses, but the physiotherapists, domestic staff and night nurses were shared between the two wards. Features of the outbreak The outbreak occurred in April 1979. Fifteen of the 24 patients on ward A developed symptoms which consisted of nausea, vomiting and diarrhoea. The distribution of cases according to age is shown in Figure 1. The illness was characterized by frequent profuse watery stools and lasted for a period of 48-72 h. The ages of
Figure 1. Distribution of casesaccording to age in (a) ward A and (b) ward B. Out of 44 staff (aged 20-50 years), five showed symptoms.
affected patients ranged from 61 to 90 years with the exception of one patient aged 42. A nurse (aged 20 years) also became ill. While investigating the outbreak on ward A, it became apparent that a similar episode had taken place on ward B ; seven patients (aged 70-90 years), one child (aged 2 years) and four members of the staff developed mild symptoms. The outbreak on the two wards lasted for a period of three weeks. As it was not possible to isolate many of the symptomatic individuals, control measureswere limited to closure of the wards to admissionsfor a period of 10 days and restriction of staff movement to other units. Materials
When routine bacteriological examination of stools from patients on ward A had failed to reveal Salmonella, Shigella or Campylobacter spp, samples from six symptomatic individuals were referred to us for screening by electronmicroscopy (EM). Rotavirus was demonstrated in four of these samples and further specimens were then collected from both patients and staff. Faecal samples were emulsified in a drop of potassium phosphotungstic acid pH 7.2 placed on a carbon formvar coated grid and examined in a Phillips EM 201 electronmicroscope. Grids were scanned at a magnification of x 20,000 for the presence of virus particles. Specimens in which organisms resembling Campylobacter were observed were cultured on C.N.V.T. medium at 43°C for 48 h. Convalescent phase sera were collected from seven symptomatic and three asymptomatic individuals on these wards. Controls consisting of sera from 10 individuals aged 70-90 years, admitted to our hospital for reasons other than gastroenteritis were included. Complement fixation tests (CFT) were performed in microtitre plates using Nebraska calf diseasevirus (NCDV) grown in LLC-MK2 cells, as the source of antigen. Results
Rotavirus was detected in six out of 18 patients examined from Ward A, (Table I). The levels of complement-fixing antibodies to rotavirus in three of these individuals (Table II) ranged from 160-320, in contrast to a titre of <20 found in serum from an asymptomatic nurse. In Ward B, rotavirus was detected in only one of nine symptomatic individuals. Specimens from these patients, however, were collected more than a week after onset of symptoms, when virus excretion would no longer be expected. Serology in three of these patients showed high titres of antibody to rotavirus (> 1280) suggestive of recent infection. In contrast sera from two asymptomatic short stay patients (Table II) had titres of (20 and 40, suggestive of past rather than recent infection. A study of sera from 10 individuals aged 72-90 years with no recent history of gastroenteritis showed titres of < 10-20. Screening of 44 members of the staff showed that three out of five symptomatic individuals were excreting rotavirus. Bacteria resembling campylobacter were detected by EM in stools from the other two individuals. This was subsequently confirmed by culture. Campylobatter was also detected in the child, in whom rotavirus was not found.
W. D. Cubitt Table
and H. Holzel
I. Results of examination No. of patients
Age (years) Ward A 31-60 61-70
8 (l)* 4 (4)
71-80 81-90 83 Staff on wards A and B 20-40 44 * ( ) Symptomatic
* ( ) Number
stools by electromicroscopy
II. Results of CFTs Control group-Asymptomatic adults
Ward B Titre t20 160 160 320
42 52 53
t2080 >1280 40
of individuals. Discussion
This report provides further evidence for the occurrence of nosocomial outbreaks of rotavirus in the elderly, and demonstrates that within this group symptoms may range from mild to severe diarrhoea. Previously we suggested that female patients aged more than 60 years were particularly susceptible (Cubitt & Holzel, 1980). Our findings on this occasion confirm this opinion. Although there was an equal number of young (30-60 years) and older (61-90 years) female patients at risk, symptoms were confined to the elderly with one exception a woman aged 42 years. In keeping with our previous findings (Cubitt & Holzel, 1980; Holzel et al., 1980) rotavirus particles were found only in faecal samples from symptomatic patients and staff. Virus was not detected in any specimen collected at the same time from 48 asymptomatic individuals on these wards (9 patients and 39 staff). Kim et al. (1977) reported that affected adults may excrete insufficient virus for detection by electronmicroscopy but do develop a rise in specific complement fixing antibodies. Our investigations of three hospital outbreaks of rotavirus infection in adults show that symptomatic patients and staff excreted virus and developed a good antibody response (CF titres 80- 2 1280). In contrast virus particles were not found in faecal samples from asymptomatic individuals and in those patients from whom serum was available titres were low (x20-40) which indicates that they were hot infected. Similar low titres ( < 10-20) were found in sera from patients of the same age group
admitted to the hospital for reasons other than gastroenteritis, a finding in agreement with a previous study of antibodies to rotavirus in different age groups (Elias, 1977). On this occasion asin the previous episodes(Cubitt & Holzel, 1980; Holzel et al., 1980) a small number of the younger members of staff displayed symptoms and were shown to be excreting rotavirus. Their role in transmission of the virus was not established, but under these circumstances it was considered prudent to screen all the staff and to exclude from duty those with symptoms or shown to be excreting virus. Staff movement from the affected wards was restricted and acute admissions to the wards halted for 10 days. These procedures proved effective in controlling the outbreak. The finding of Campylobacter spp. in three individuals during screening for rotavirus emphasisesthe point that more than one causative agent may be present during an outbreak, and also indicates the necessity for bacteriological and virological screening to be carried out in parallel. We would like to thank Dr D Rimmer and the two Ward Sisters for their help and cooperation in the investigation of this outbreak. We would also like to thank Miss C. Tham for her secretarial assistance. References Cameron, D. J. S., Bishop, R. F., Veenstra, A. A., Barnes, G. L., Holmes, I. H. & Ruck, B. J. Pattern of shedding of two non cultivable viruses in stools of newborn babies. Journal of Medical Virology 2: 7-13 (1978). Chrystie, I. L., Totterdell, B. M. & Banatvala, J. E. Asymptomatic endemic rotavirus infections in the newborn. Lancet i: 1176-l 178 (1978). Cubitt, W. D. & Holzel, H. An outbreak of rotavirus infection in a longstay ward of a geriatric hospital. Journal of Clinical Pathology 33: 306-308 (1980). Elias, M. M. Distribution and titres of rotavirus antibodies in different age groups. Journal of Hygiene, Cambridge 79: 365-372 (1977). Flewett, T. H., Bryden, A. S., Davies, H. & Morris, C. A. Epidemic viral enteritis in a long-stay children’s ward. Lancet i: 4-5 (1975). Halvosrud, J. & Orstavik, I. An epidemic of rotavirus associated gastroenteritis in a nursing home for the elderly. Scandinavian Journal of Infectious Diseases 12: 161-164 (1980). Holzel, H., Cubitt, W. D., McSwiggan, D. A., Sanderson, P. J. & Church, J. An outbreak of rotavirus infection in a cardiology ward. Journal of Infection 2: 33-37 (1980). Kim, H. W., Brandt, C. D., Kapikian, A. Z., Wyatt, R. G., Arrobio, J. O., Rodriguez, W. J., Chanock, R. M. & Parrott, R. H. Human reovirus-like agent infection:Occurrence in adult contacts of paediatric patients with gastroenteritis. Journal of the American Medical Association 238 : 404-407 (1977). Meurman, 0. H. & Lane, M. J. Rotavirus epidemic in adults. New England Journal of Medicine 296 : 1298-l 299 (1977). Middleton, P. J., Szymanski, M. T., Abbott, G. D., Bortolussi, R. & Hamilton, J. R. Orbivirus acute gastroenteritis of infancy. Lancet i: 1241-1244 (1974). Middleton, P. J., Szymanski, M. T. & Petric, M. Viruses associated with acute gastroenteritis in young children. American Journal of Diseases of Children 131: 733-737 (1977). Ryder, R. W., McGowan, J. E. jr., Hatch, M. H. & Palmer, E. L. Reovirus like agent as a cause of nosocomial diarrhoea. Journal of Paediatrics 90: 698-702 (1977). Tufvesson, B., Johnsson, T. & Persson, B. Family infections by reolike virus. Comparison of antibody titres by complement fixation and immunoelectroosmophoresis. Scandinavian Journal of Infectious Diseases 9: 257-261 (1977). Von Bonsdorff, C. H., Hovi, T., Makela, P. & Morttinen, A. Rotavirus infections in adults with acute gastroenteritis. Journal of Medical Virology 2: 21-28 (1978).