ROTAVIRUSES-ASSOCIATED

GASTROENTERITIS

Khalifa Sifaw Ghenghesh1, Mohamed Kreasta2, and

Mohamed El-Bakoush3 and Rajab Tobgi4

Dept. of Medical Microbiology1, Dept. of Pediatrics2, and

Dept. of Community Medicine3,
Faculty of Medicine, El-Fateh University, Tripoli, and
Tuberculosis Center 4, Benghazi, Libya

Correspondence:
Professor Khalifa Sifaw Ghenghesh, MSc, PhD, DipBact
Department of Medical Microbiology,
Faculty of Medicine,
Al-Fateh University,
P.O. Box 80013,
Tripoli-Libya
E-mail: ghenghesh_micro@yahoo.com

To cite this paper:

Ghenghesh KS., Kreasta M., El-Bakoush M., and Tobgi R. 2002. Rotaviruses-
Associated Gastroenteritis. Jamahiriya Med J; 2 (2): 12-17.
INTRODUCTION:
Diarrhoea is a worldwide problem affecting mainly children. Among the
established agents, rotaviruses are considered the most common cause of
acute gastroenteritis in young children in both developed and developing
countries (1). In the latter it is estimated that 20% to 70% of hospitalizations and
around 900.000 children below the age of 5 die annually as a result of
rotaviruses infection (2). This review is intended to give a good insight on
rotaviruses with regard to their morphology and classification, epidemiology,
pathogenesis and clinical manifestation, laboratory diagnosis, treatment and
prevention. This review also includes a section on rotavirus in the Libyan Arab
Jamahiriya.

ROTAVIRUS MORPHOLOGY AND CLASSIFICATION:

The genus rotavirus belongs to the family Reoviridae. Rotavirus is non-
enveloped virus and its genome consists of 11 segments of double-stranded
RNA (dsRNA), each encoding at least one virus protein (VP) of which six are
structural (VP1-VP4, VP6 and VP7) and five are nonstructural (NSP1-NSP5)
(3). Particles of rotaviruses possess a triple-shelled (outer, intermediate and
inner layer) capsid. VP1, VP2 and VP3 are contained in the inner; VP6 in the
intermediate, and VP4 and VP7 in the outer layer (Figure). Segmented nature of
rotavirus genome results in genetic re-assortment, which occurs at high
frequency during infection (4).

Transmission electron micrograph of intact rotavirus particles, double-

shelled (CDC/Dr. Erskine Palmer).
Groups, subgroups, serotypes, genotypes and electrophoretic types of
rotaviruses:
Rotaviruses are divided to at least seven groups (A-G) based on group
specificity, which is conferred mainly by VP6 (4). VP6 antigen also determines
subgroup (SG) specificity, which classifies group A rotaviruses into four
categories (SG I, SG II, SG I and SG II, or non-SG I and non-SG II strains) by
their reactivity with the VP monoclonal antibodies (5). In epidemiological studies
this specificity has been used widely to characterize the antigenic properties of
rotavirus strains. Rotavirus serotypes are determined by VP7 and VP4. Based
on their ability to elicit neutralizing antibody responses, VP7 (encoded by gene
segment 7, 8 or 9, depending on the strain) and VP4 (encoded by gene
segment 4), independently specify the G (standing for glycoprotien) and P
(standing for protease-sensitive protein) types, respectively. Various
combinations of G and P types have been detected in natural isolates as a
result of independent segregation of VP7 and VP4 genes (6,7). To date at least
10 of the 14 different G types (G1-G14) and 11 of 20 different P types (P1-P20)
have been detected in man. Due to the difficulty in differentiating the P serotype
serologically, the term "VP4 genotype", based on the VP4 sequence, has been
proposed (8). Using PCR techniques, P and G genotyping has been reported by
several investigators from different countries (9-12). Electrophoretic typing is
carried out by polyacramide gel electrophoresis (PAGE). Two major patterns of
migration of the 11th genomic segment, one slower and another faster, can be
detected. These patterns also called "short" and "long" patterns respectively.
Usually the "short" pattern is found in SG I, whereas the "long" pattern in SG II
samples (13).

EPIDEMIOLOGY:
Rotaviruses-associated gastroenteritis is omnipresent occurring
worldwide and usually caused by group A. Groups B and C (non-group A
rotaviruses [NGARV]) also occur in humans and have been reported in sporadic
cases. However, few studies reported detection of NGARV with rates as high as
4% (14). Furthermore, NGARV appear to be associated with diarrhoea in adults
and older children more than in neonates, (14-18), suggesting that NGARV may
be emerging enteric pathogens in older humans (19). Other groups (D-G) have
not been detected in humans.
 Most (> 90%) of rotaviruses-associated diarrhoeal episodes in children
are caused by serotypes G1 to G4 (20), while the most commonly found P
serotypes are P[8] and P[4] (9). Atypical strains have been reported in several
countries. In one study from India more than 60% of cases were found to be
associated with atypical serotypes (21). This could be due to the occurrence of
re-assortment between common and uncommon serotypes or animal strains
(22, 23).
Rotaviruses infection occurs via the faecal-oral route. Occurrence rates
are similar in developing and developed countries. The possibility of
transmission via the respiratory tract has been suggested due to the lack of
evidence for transmission of rotaviruses by the faecl-oral route in several
outbreaks (2). By the age of 5 years more than 90% of children expected to be
infected by rotaviruses, and most have repeated infections (24,25).
It has been observed that the median age of illness due to rotaviruses is
younger (6-8 months) in tropical than that in temperate countries (14-18
months). This could be due to seasonality differences of rotavirus infection in
these countries (26). In developing countries rotavirus infection occurs
throughout the year with children can be exposed at any day of the year. On the
other hand in developed countries the disease reaches its peak in winter with
children born at the end of such peak must wait a full year until they are next
exposed to rotavirus (27,28).
Dutta et al (29) reported that children of mothers with university
education showed a higher level of rotavirus infection in comparison to children
of mothers with school level education or no education. These investigators also
detected rotavirus more often in patients from higher income homes compared
to a lower income group. Furthermore, they found no significant difference in
rotavirus positivity between children of working and non-working mothers.
Other studies have shown that exposure to other children with diarrhoea
is the single most important factor for acquiring rotavirus diarrhoea (30). Other
significant risk factors were living in homes with septic tanks and in homes with
'poor environmental sanitation'. Minimizing contacts of children with diarrhoea
therefore would be the most effective measure in preventing the spread of this
disease in the community.
Rotaviruses are responsible for more than 50% of episodes of acute
diarrhea requiring hospital admission in children less than 2 years (31). Several
outbreaks of rotavirus gastroenteritis have occurred in hospitals and day care
centers. Nosocomial infections are frequent and account for up to 50% of
rotavirus cases occurring in the hospital (32). Shared toys that may have served
as fomites in transmission of rotavirus have been implicated in an outbreak of
nosocomial rotavirus infection on a pediatric oncology floor (33).

CLINICAL INFECTION AND PATHOGENESIS:

After 1-2 days incubation period, rotavirus gastroenteritis is characterized
by sudden onset with vominting, diarrhoea, and fever. Loss of fluids and
electrolytes can result in severe dehydration, hospitalization and even death
(32). Rotavirus pathogenesis is still not well understood, despite extensive
studies in different animal models (34). Several pathophysiological mechanisms
by which the virus causes diarrhoea have been proposed. Among these, are
destruction of the enterocytes (35) and alteration in transepithelial fluid balance
(36), resulting in malabsorption. Studies had also shown that the nonstructural
protein (NSP4) to be an enterotoxin, causing diarrhoea in mouse pups (37).
This enterotoxin causes chloride secretion by activating a signal transduction
pathway that increases intracellular calcium levels in cell by mobilizing calcium
from endoplasmic reticulum (37-40.). The role of this enterotoxin in causing
diarrhoea have been supported by recent studies in which side-direct mutations
in NSP4 were made that resulted in altered virus virulence (34).

LABORATORY DIAGNOSIS:
Stool samples collected from patients are usually examined for rotavirus
antigen using any of the several latex agglutination tests or enzyme
immunoassays (EIA) that are available commercially. Although, EIA is more
sensitive, these assays are reliable and reasonably priced. Observing virus
particles by electron microscopy is still regarded by some as the gold standard
of rotavirus diagnosis (41). However, use of EM is laborious, expensive and is
not available in many developing countries. In the last decade a number of PCR
(polymerase chain reaction) techniques have been used to detect the virus in
stool samples. These techniques can detect smaller quantities of rotavirus in
stool and have been shown to increase the detection rate by 15-20% (42-45).
Recently, Pang XL et al (46) reported even a higher rate (33%), using reverse-
transcription polymerase chain reaction (RT-PCR) when compared with EIA.
Although, current generation EIA kits demonstrated to serve as excellent
rotavirus detection system yielding sensitivities and specificities of 100% and
99% respectively (47), PCR techniques have the advantage of their ability to be
used in genotyping of causative rotaviruses strains by characterization of the G
and P outer capsid protein.

TREATMENT AND PREVENTION:

Since there is no effective antiviral agents available for specific treatment
supportive therapy that includes fluid and electrolyte replacement, either orally
or intravenously, is the cornerstone of rotaviruses-associated gastroenteritis
treatment. Some studies reported that breast-feeding might have a preventative
effect while it continues, but there is evidence of catch-up infection at weaning
(48).
Due to the universality of rotaviruses in infecting children up to 5 years in
developing and developed countries, regardless of social, economic or hygienic
standards, having a vaccine to control rotaviral disease has been shown by
epidemiolgical studies to be the logical solution. Another observation in support
of having a vaccine for rotaviruses is that infants infected with rotavirus in the
first month of life were less likely to have moderate-to-severe disease
associated with reinfection than those who were not infected (49). In the last 3
decades a number of vaccines have been tested in clinical trials in several
countries. In the early vaccines the Jenner's approach to the smallpox
vaccination was employed. In this approach an antigenically related, live non-
human rotavirus strain that induces a protective immune response but not
disease in humans was used. However, non-human vaccine candidates were
not consistently effective in protecting infants from rotavirus disease (50).
As the non-human rotavirus strains were tolerated well in all trials,
researchers embarked on developing a vaccine that retained the attenuated
virulence characteristics of the non-human rotavirus strains but possess human
rotavirus genes responsible for determining serotype. Using reassortment
techniques (by infecting cell cultures with two different viruses) a number of
rotavirus strains, that contained all rotavirus genes from animal strain and one
of the genes from human rotavirus strains (51), were developed as vaccine
candidates. The most widely tested of these vaccines in clinical trials is the
tetravalent rhesus-human reassortment rotavirus vaccine (RRV-TV). RRV-TV
contains a rhesus rotavirus with serotype G3 specificity and reassortment
rhesus-human rotaviruses with G1, G2, and G4 specificity.
In trials in several industrialized countries the vaccine had demonstrated
49-68% protection against any rotavirus diarrhoea, 61-91% protection severe
diarrhoea, and 50-100% efficacy in preventing doctors visits for diarrhoea (52-
55.). A clinical trial was carried out in a poor population in Venezuela (a
developing country) with the aim to evaluate the efficacy of the vaccine against
dehydration as the primary end point (56). In this trial the vaccine gave 88%
protection against severe diarrhoea caused by rotavirus, 75% protection against
dehydration, 70% reduction in hospital admissions, and 48% efficacy against a
first episode of rotavirus diarrhoea.
In August 1998 the Food and Drug Administration (FDA) in the United
States licensed RRV-TV under the trade name "RotaShield". Post licensure
surveillance detected a probable association with intussusception among
recipients of the vaccine (57). Others failed to show an appreciable increase in
the incidence of intussusception after introduction of the rotavirus vaccine (58).
However, the American Academy of Pediatrics on July 1999 recommended the
temporary suspension of administration of RRV-TV vaccine (59), the withdrawal
of the vaccine from the market by the manufacturer then followed.
Despite this drawback, a number of non-Jennerian approaches for
developing more promising vaccines have been used and still in progress.
Among these are, the attenuated human rotaviruses (60), baculovirus-
expressed virus-like particles which are essentially viral capsids which contain
no genetic material, and naked DNA vaccines is another approach used to
develop rotavirus vaccines (61,62).

ROTAVIRUS IN LIBYAN ARAB JAMAHIRIYA:

In the past, studies carried out in Libya on diarrhoea in children were few
and on rotavirus were rare. The first study on rotavirus in Libya was published in
1980 by Abrar et al (63). They measured rotavirus-antibodies in the sera of 51
children in Benghazi aged 5 years and reported 100% positivity. The study did
not specify the clinical symptoms of the children and whether they had
diarrhoea or not. From the available limited data in Libya, rates of rotavirus
infection in children with diarrhoea ranged between > 20% to 32% (64-66).
There is no seasonal variation in the occurrence of rotavirus infection, although
it appears to peak in autumn. This data also shows that rotavirus is the leading
cause of gastroenteritis in children in the Libyan Arab Jamahiriya and may be
responsible for a large part of the morbidity and mortality that is associated with
this syndrome. This is supported by the findings of a recent study from Zliten
(67), in which 98% of rotavirus-positive children with diarrhoea were dehydrated
and more than 84% with fever and vomiting. In the future, studies are needed
on several issues regarding rotaviruses-associated gastroenteritis in Libya to
answer a number of raised questions. Among these, what is the incidence of
rotavirus infection in different communities and different age groups including
adults? What are the rates of nosocomial- and nurseries-acquired rotavirus
infections? Is there a place for a rotaviruses-vaccine in the national vaccination
program? And if so, what are the groups, serotypes, genotypes and
electrophoretic types of the strains that circulate in the country. We believe that
an effort should be made by the medical research centers, universities, and
health authorities working together to find the proper solutions for this potentially
deadly illness.

REFERENCES:
1. Kapikian AZ. and Chanock RM. 1996. Rotaviruses. In: Fields BN., Knipe
DM., Howley PM., et al. (eds.), Fields Virology (3rd ed., vol 2). Lippincott-Raven,
Philadelphia. pp. 1657-1708.).
2. Parashar UD., Bresee JS., Gentsch JR. and Glass RI. 1998. Rotavirus.
Emerg Infect Dis; 4: 561-570.
3. Shen S., McKee TA., Wang ZD., Desselberger U., and Liu DX. 1999.
Sequence analysis and in vitro expression of genes 6 and 11 of an ovine group
B rotavirus isolate, KB63: evidence for a non-defective, C-terminally truncated
NSP1 and a phosphorylated NSP5. J Gen Virol; 80: 2077-2085.
4. Hoshino Y. and Kapikian AZ. 2000. Rotavirus serotypes: classification and
importance in epidemiology, immunity, and vaccine development. J Health
Popul Nutr; 18: 5-14.
5. Sebata T. and Duncan Steele A. 2001. Atypical rotaviruses identified from
young children with diarrhoea in South Africa. J Health Popul Nutr; 19: 199-203.
6. Estes M., 1996. Rotaviruses and their replication. In: Fields BN. et al. (eds.),
Fields Virology (3rd ed., vol 2). Lippincott-Raven, Philadelphia, Pa. pp. 1625-
1655.
7. Taniguchi K., Urasawa T., and Urasawa S. 1993. Independent segregation of
the VP4 and the VP7 genes in bovine rotaviruses as confirmed by VP4
sequence analysis of G8 and G10 bovine rotavirus strains. J Gen Virol; 74:
1215-1221.
8. Tangiguchi K., and Urasawa S. 1995. Diversity in rotavirus genomes.
Virology; 6: 123-131.
9. Asmah RH., Green J., Armah GE., et al. 2001. Rotavirus G and P in rural
Ghana. J Clin Microbiol; 39: 1981-1984.
10. Audu R., Aremu Omilabu S., de Beer M., Peenze I., and Duncan Steele A.
2002. Diversity of human rotavirus VP6, VP7, and VP4 in Lagos State, Nigeria.
J Health Popul Nutr; 20: 59-64.
11. Cascio A., Vizzi E., Aliamo C., and Arista S. 2001. Rotavirus gastroenteritis
in Italial children: can severity of symptoms be related to the infecting virus?
CID; 32: 1126-1132.
12. Mascarenhas JDP., Paiva FL., Barardi CRM., Gabbay YB., Simoes CO.,
and Linhares AC. 1998. Rotavirus G and P types in children from Belem,
Northern Brazil, as determined by RT-PCR: occurrence of mixed P type
infections. J Health Popul Nutr; 16: 8-14.
13. Cardoso DP., Soares CA., Azevedo MSP., Leite JPG., Munford V., and
Racz ML. 2000. Serotypes and subgroups of rotavirus isolated from children in
central Brazil. J Health Popul Nutr.; 18: 39-43.).
14. Bridger JC. 1994. Non-group A rotaviruses. In: Kapikian AZ (ed.) Viral
infections of the gastrointestinal tract. Marcel Dekker, New York. pp. 369–408.
15. Saif LJ. 1990. Nongroup A rotaviruses. In: Saif LJ. and Theil KW. (eds.)
Viral diarrheas of man and animals. CRC Press, Boca Raton, Fla. pp. 73-95.
16. Jaing B., Dennehy PH., Spangenberger S., Gentsch JR. and Glass RI.
1995. First detection of group C rotavirus in fecal specimens of children with
dirrea in the United States. J Infect Dis; 172: 45-50.
17. Penaranda ME., Cubitt WD., Sinarachatanant P., et al. 1989. Group C
rotavirus infections in patients with diarrhea in Thailand, Nepal and England. J
Infect Dis; 160: 392-397.
18. Ushijima H., Honma H., Huhoyama A., et al. 1989. Detection of group C
rotaviruses in Tokyo. J Med Virol; 27: 299-303.
19. Kim Y., Chang K-O, Straw B. and Saif LJ. 1999. Characterization of Group
C rotaviruses associated with diarrhea outbreaks in feeder pigs. J Clin
Microbiol; 37: 1484-1488.
20. Bishop RF. 1985. Epidemiology of diarrheal disease caused by rotavirus. In:
Holmgren J., Lindburg A. and Mollby R. (eds.) Development of vaccines and
drugs against diarrhea. Proceedings of the 11th Nobel Conference. Stockholm:
Studentlitteratur, Lund. pp. 158–170.
21. Ramachandran M., Das BK., Vij A., et al. 1996. Unusual diversity of human
rotavirus G and P genotypes in India. J Clin Microbiol; 34:436–439.
22. Gentsch JR., Woods PA., Ramachandran M., et al. 1996. Review of G and
P typing results from a global collection of rotavirus strains: Implications for
vaccine development. J Infect Dis 1996; 174(suppl): S30–36.
23. Palombo EA., Bugg HC., Masendycz PJ., Coulson BS., Barnes GL., and
Bishop RF. 1996. Multiple-gene rotavirus reassortants responsible for an
outbreak of gastroenteritis in central and northern Australia. J Gen Virol;
77:1223–1227.
24. Gurwith M., Wenman W., Hinde D., Feltham S., Greenberg H. 1981. A
prospective study of rotavirus infection in infants and young children. J Infect
Dis; 144: 218–224.
25. Velazquez FR., Matson DO., Calva JJ., et al. 1996. Rotavirus infections in
infants as protection against subsequent infections. N Engl J Med; 335: 1022–
1028.
26. Bresse J., Glass RI., Ivanoff B., Gentsch J., 1999. Current status and future
priorities for rotavirus vaccine development, evaluation, and implementation in
developing countries. Vaccine; 17: 2207-2222.
27. Cook SM., Glass RI., LeBaron CW. and Ho MS. 1990. Global seasonality of
rotavirus infections. Bull World Health Organ; 68: 171-177.
28. Man NV., Trang NV., Lien HP., et al. 2001. The epidemiology and disease
burden of rotavirus in Vietnam: sentinel surveillance at 6 hospitals. J Infect Dis;
183: 1707-1712.
29. Dutta SR., Khalfan SA., Baig BH., Philipose L. and Fulayfil R. 1990.
Epidemiology of rotavirus diarrhoea in children under five years in Bahrain. Int J
Epidemiol; 19: 722-727.
30. Menon S. Santosham M., Reid R., Almeido-Hill J., Sack RB., Comstock
GW. 1990. Rotavirus diarrhoea in Apache children: a case-control study. Int J
Epidemiol; 19: 715-721.
31. Barnes GL., Uren E., Stevens KB. and Bishop RF. 1998. Etiology of acute
gastroenteritis in hospitalized children in Melbourne, Australia, from April 1980
to March 1993. J Clin Microbiol; 36: 133–138.
32. Christensen ML. 1995. In: Murray PR., Baron EJ., Pfaller MA., Tenover FC.
and Yolken RH. (eds.), Manual of Clinical Microbiology (6th ed.). ASM Press,
Washington, DC. pp. 1012-1024.
33. Rogers M., David M., Weinstock DM., Eagan J., Kiehn T., Armstrong D. and
Sepkowitz KA. 2000. Rotavirus outbreak on a pediatric oncology floor: Possible
association with toys. Am J Infect Control; 28: 378-380.
34. Zhang M., Zeng CQY., Dong Y., et al. 1998. Mutation in rotavirus
nonstructural glycoprotein NSP4 are associated with altered virus virulence. J
Clin Microbiol; 72: 3666-3672.
35. Graham DY., Sackman JW., and Estes MK. 1984. Pathogenesis of
rotavirus-induced diarrhea: prelinminary studies in miniature swine piglet. Digest
Dis Sci; 29: 1028-1035.
36. Collins J., Starkey WG., Wallis TS., et al. 1988. Intestinal enzyme profiles in
normal and rotavirus-infected mice. J Pediatr Gastroenterol Nutr; 7: 264-272.
37. Ball JM., Peng T., Zeng CQY., Morris AP. and Estes MK. 1996. Age-
dependent diarrhoea induced by a rotaviral nonstructural glycoprotein. Science;
272: 101-104.
38. Dong YJ., Zeng CQY., Ball JM., Estes MK. and Morris AP. 1997. The
rotavirus enterotoxin NSP4 mobilizes intracellular calcium in human intestinal
cells by stimulating phospholipase C mediated inositol 1,4,5-triphosphate
production. Proc Natl Acad Sci USA; 94: 3960-3965.
39. Tian P., Estes MK., Hu Y., Ball JM., Zeng CQY., and Schilling WP. 1995.
The rotaviral nonstructural glycoprotein NSP4 moblizes Ca2+ from the
endoplasmic reticulum. J Virol; 69: 5763-5772.
40. Tian P., Hu Y., Schilling WP., Lidsay DA., Eiden J., and Estes MK. 1994.
The nonstructural glycoprotin of rotavirus affects intracellular calcium levels. J
Virol; 68: 251-257.
41. Doane FW. 1994. Electron microscopy (EM) for detection of gastroenteritis
viruses. In: Kapikian AZ (ed.). Viral infections of the gastrointestinal tract (2nd
ed.). Dekker, New York. pp. 101-130.
42. Xu L., Harbour D., and MaCrae MA. 1990. The application of polymerase
chain reaction to the detection of rotaviruses in faeces. J Virol Method; 27: 29-
38.
43. Guevea V., Allen JR., Glass RI., et al. 1991. Detection of group B and C
rotaviruses by polymerase chain reaction. J Clin Microbiol; 29: 519-523.
44. Wilde J., Eiden J. and Willoughby J. 1991. Improved detection of rotavirus
shedding by polymerase chain reaction. Lancet; 337: 323-326.
45. Wilde J., Van R., Pickering L., Eiden J., and Yolken R. 1992. Detection of
rotaviruses in day care environment by reverse transcriptase polymerase chain
reaction. J Infect Dis; 166: 507-511.
46. Pang XL., Joensuu J., Hoshino Y., Kapikian AZ., and Vesikari T. 1999.
Rotaviruses detected by reverse transcription polymerase chain reaction in
acute gastroenteritis during a trail of rhesus-human reassortant rotavirus
tetravalent vaccine: implication for vaccine efficacy analysis. J Clin Virol; 13: 9-
16.
47. Lipson SM., Svenssen L., Goodwin L., Porti D., Danzi S., and Pergolizzi R.
2001. Evaluation of two current generation enzyme immunoassays and
improved isolation-based assay for rapid detection and isolation of rotavirus
from stool. J Clin Virol; 21: 17-27.
48. Clemens J., Rao M., Ahmed F., et al. 1993. Breast-feeding and the risk of
life-threatening rotavirus diarrhea: Prevention or postpone? Pediatrics 1993; 92:
680–685.
49. Bishop RF., Barnes GL., Cipriani E., and Lund JS. 1983. Clinical immunity
after neonatal rotavirus infection: A prospective longitudinal study in young
children. N Engl J Med; 309: 72–6.
50. Offit PA. 1998. The rotavirus vaccine. J Clin Virol; 11: 155-159.
51. Midthun K., and Kapikian AZ. 1996. Rotavirus vaccines: an overview. Clin
Microbiol Rev; 9: 423-434.
52. Joensu J., Koskenniemi E., Pang X-L., and Vesikari T. 1997. A randomized,
double-blind placebo controlled trail of rhesus-human reassortment rotavirus
vaccine for prevention of severe rotavirus gastroenteritis. Lancet; 350: 1205-
1209.
53. Rennels MB., Glass RI., Dennehy PH., etal. 1996. Safety and efficacy of
high-dose rhesus-human reassortment rotavirus vaccine-report of the national
multicenter trial. Pediatrics; 97: 7-13.
54. Santosham M., Moulten LH., Reid R., etal. 1907. Efficacy and safety of
high-dose rhesus-human reassortment rotavirus vaccine in Native Americans
populations. J Pediatr; 131: 632-632.
55. Bernstein DI., Glass RI., Rodgers G., Davidson BL., Sack DA. And U.S.
Rotavirus Vaccine Efficacy Group. 1995. Evaluation of rhesus rotavirus
monovalent and tetravalent reassortment vaccines in US children. JAMA; 273:
1191-1196.
56. Perez-Sachael I., Guntinas MJ., Perez M., etal. 1997. Efficacy of the rhesus
rotavirus-based quadrivalent vaccine in infants and young children in
Venezuela. N Engl J Med; 337: 1181-1187.
57. Centers for Disease Control and Prevention (CDC). 1999. Intussusception
among recipients of rotavirus vaccine: United States 1998–1999. Morb Mortal
Wkly Rep 1999;48:577–581.
58. Chang H-G., Smith PF., Ackelsberg J., Dale L. Morse DL. and Roger I.
Glass RI. 2001. Intussusception, rotavirus diarrhea, and rotavirus vaccine use
among children in New York State. Pediatrics; 108: 54-60.
59. Barnes G. 2000. Rotavirus vaccine. J Peditr Gastroenterol Nutr; 30: 12-17.
60. Vesikari T., Ruuska T., Koivu H., Green KY., Flores J., and Kapikian AZ.
1991. Evaluation of the M37 human rotavirus vaccine in 2- to 6-month-old
infants. Pediatr Infec Dis J; 10: 912-917.
61. Conner ME., Zarley CD., Hu B., etal. 1996. Virus-like particles as a rotavirus
subunit vaccine. J Infect Dis; 174: S88-S92.
62. Herrmann JE., Chen SC., Fynan EF., etal. 1996. Protection against
rotavirus infections by DNA vaccination. J Infect Dis; 174: S93-S97.
63. Abrar M., Marshall WC., Hawkins GT., and Leung T. 1980. Rotavirus,
rubella and cytomegalovirus antobodies: a study in Benghazi children.
Garyounis Med J; 3: 95.
64. Giasuddin ASM., Boryswick G. and Abusedra A. 1990. Rotavirus-associated
diarrhoeal disease in Libyan infants up to one year of age. J Islamic Acad Sci;
3: 218-220.
65. Ghenghesh KS., Abeid SS., Bara F. and Bukris B. 2001. Etiology of
childhood diarrhoea in Tripoli-Libya. JMJ; 1(2): 23-29.
66. Ben Ali M., Ghenghesh KS., Abuhelfaia A. and Dufani MA. 2001. Causative
agents of children diarrhoea in Zliten-Libya. 21st Congress of the Brazillian
Society for Microbiology (abstract). Voz de Iguacu, Brazil, 21-25 October.
67. Ben Ali M. 2001. Causative agents of children diarrhoea in Zliten. MSc
dissertation (in Arabic). Faculty of Arts and Sciences, El-Ghomes University, El-
Ghomes-Libya.