Introduction: Despite its recent status of middle-income country in WHO’s South-East Asia Region, diarrhea remains an important yet unresearched public health issue in the Republic of Maldives. Methodology: We conducted a one-month cross-sectional study in children and adults with acute diarrhea at three regional hospitals in Maldives in August-September 2007 to investigate the point-prevalence of diarrhea etiologic agents. Enteric Bacteria was identified by a standard microbiology technique and isolates were submitted for antimicrobial susceptibility testing. Rotavirus, astrovirus and adenovirus were detected by enzyme-linked immunosorbent assays (ELISA). Real-time reverse-transcription polymerase chain reaction (RT-PCR) was used to test for norovirus. Results: We enrolled 73 children and 57 adults with acute diarrhea. The most common pathogens detected in children were norovirus (43%) and rotavirus (18%). Vibrio parahaemolyticus (18%) and rotavirus (17%) were the most common pathogens found in adults. Multiple and mixed infections were common. All noroviruses were identified as genogroup II/type 4(GII/4). The genotype distributions of rotaviruses were G2P[4] (48%), G12P[6] (37%), G2P[6] (5%), G9P[8] (5%), and non-typeable G2 (5%). Conclusions: This study provides preliminary data on the importance of norovirus and rotavirus as diarrhea etiologic agents in Maldives. A systematic prospective diarrhea surveillance documenting disease burden, etiology, seasonal variation, as well as risk factors should be conducted for the development of public health interventions to reduce diarrhea morbidity and mortality in Maldives.
References
[1]
European External Action Service (2007) The Maldives—European Community Country Strategy Paper 2007-2013. http://eeas.europa.eu/maldives/csp/07_13_en.pdf
[2]
Epidemiology and Disease Surveillance Unit, Ministry of Health, Republic of Maldives (2010) Epidemiological Report 1. http://www.health.gov.mv/publications/epi%20report%202010.pdf
Clinical and Laboratory Standards Institute (2007) Performance Standards for Antimicrobial Susceptibility Testing; Seventeenth Informational Supplement. CLSI Document M100-S17, Clinical and Laboratory Standards Institute, Pennsylvania.
[5]
Kageyama, T., Kojima, S., Shinohara, M., Uchida, K., Fukushi, S., Hoshino, F.B., Takeda, N. and Katayama, K. (2003) Broadly Reactive and Highly Sensitive Assay for Norwalk-Like Viruses Based on Real-Time Quantitative Reverse Transcription-PCR. Journal of Clinical Microbiology, 41, 1548-1557. http://www.ncbi.nlm.nih.gov/pubmed/12682144 http://dx.doi.org/10.1128/JCM.41.4.1548-1557.2003
[6]
Vinje, J., Vennema, H., Maunula, L., von Bonsdorff, C.H., Hoehne, M., Schreier, E., Richards, A., Green, J., Brown, D., Beard, S.S., Monroe, S.S., de Bruin, E., Svensson, L. and Koopmans, M.P. (2003) International Collaborative Study to Compare Reverse Transcriptase PCR Assays for Detection and Genotyping of Noroviruses. Journal of Clinical Microbiology, 41, 1423-1433. http://www.ncbi.nlm.nih.gov/pubmed/12682125 http://dx.doi.org/10.1128/jcm.41.4.1423-1433.2003
[7]
Gentsch, J.R., Glass, R.I., Woods, P., Gouvea, V., Gorziglia, M., Flores, J., Das, B.K. and Bhan, M.K. (1992) Identification of Group A Rotavirus Gene 4 Types by Polymerase Chain Reaction. Journal of Clinical Microbiology, 30, 1365-1373. http://www.ncbi.nlm.nih.gov/pubmed/1320625
[8]
Iturriza-Gomara, M., Kang, G. and Gray, J. (2004) Rotavirus Genotyping: Keeping up with an Evolving Population of Human Rotaviruses. Journal of Clinical Microbiology, 31, 259-265. http://www.ncbi.nlm.nih.gov/pubmed/15494266 http://dx.doi.org/10.1016/j.jcv.2004.04.009
[9]
Castello, A.A., Arguelles, M.H., Rota, R.P., Olthoff, A., Jiang, B., Glass, R.I., Gentsch, J.R. and Glikmann, G. (2006) Molecular Epidemiology of Group A Rotavirus Diarrhea among Children in Buenos Aires, Argentina, from 1999 to 2003 and Emergence of the Infrequent Genotype G12. Journal of Clinical Microbiology, 44, 2046-2050. http://www.ncbi.nlm.nih.gov/pubmed/16757596 http://dx.doi.org/10.1128/JCM.02436-05
[10]
Chhabra, P. and Chitambar, S.D. (2008) Norovirus Genotype IIb Associated Acute Gastroenteritis in India. Journal of Clinical Virology, 42, 429-432. http://www.ncbi.nlm.nih.gov/pubmed/18467163 http://dx.doi.org/10.1016/j.jcv.2008.03.014
[11]
Dey, S.K., Nguyen, T.A., Phan, T.G., Nishio, O., Salim, A.F., Rahman, M., Yagyu, F., Okitsu, S. and Ushijma, H. (2007) Molecular and Epidemiological Trend of Norovirus Associated Gastroenteritis in Dhaka City, Bangladesh. Journal of Clinical Virology, 40, 218-223. http://www.ncbi.nlm.nih.gov/pubmed/17881286 http://dx.doi.org/10.1016/j.jcv.2007.08.005
[12]
Kittigul, L., Pombubpa, K., Taweekate, Y., Yeephoo, T., Khamrin, P. and Ushijima, H. (2009) Molecular Characterization of Rotaviruses, Noroviruses, Sapovirus, and Adenoviruses in Patients with Acute Gastroenteritis in Thailand. Journal of Medical Virology, 81, 345-353. http://www.ncbi.nlm.nih.gov/pubmed/19107961 http://dx.doi.org/10.1002/jmv.21380
[13]
Parashar, U.D., Hummelman, E.G., Bresee, J.S., Miller, M.A. and Glass, R.I. (2003) Global Illness and Deaths Caused by Rotavirus Disease in Children. Emerging Infectious Diseases, 9, 565-572. http://dx.doi.org/10.3201/eid0905.020562 http://www.ncbi.nlm.nih.gov/pubmed/12737740
[14]
Tate, J.E., Burton, A.H., Boschi-Pinto, C., Steele, A.D., Duque, J. and Parashar, U.D. (2012) 2008 Estimate of Worldwide Rotavirus-Associated Mortality in Children Younger than 5 Years before the Introduction of Universal Rotavirus Vaccination Programmes: A Systematic Review and Meta-Analysis. Lancet Infectious Diseases, 12, 136-141. http://www.ncbi.nlm.nih.gov/pubmed/22030330 http://dx.doi.org/10.1016/S1473-3099(11)70253-5
[15]
Wenman, W.M., Hinde, D., Feltham, S. and Gurwith, M. (1979) Rotavirus Infection in Adults. Results of a Prospective Family Study. The New England Journal of Medicine, 301, 303-306. http://www.ncbi.nlm.nih.gov/pubmed/221816
[16]
Von Bonsdorff, C.H., Hovi, T., Makela, P., Hovi, L. and Tevalvoto-Aarnio, M. (1976) Rotavirus Associated with Acute Gastroenteritis in Adults. The Lancet, 2, 423. http://www.ncbi.nlm.nih.gov/pubmed/73889
[17]
Rubilar-Abreu, E., Hedlund, K.O., Svensson, L. and Mittelholzer, C. (2005) Serotype G9 Rotavirus Infections in Adults in Sweden. Journal of Clinical Microbiology, 43, 1374-1376. http://www.ncbi.nlm.nih.gov/pubmed/15750111 http://dx.doi.org/10.1128/jcm.43.3.1374-1376.2005
[18]
Anderson, E.J., Katz, B.Z., Polin, J.A., Reddy, S., Weinrobe, M.H. and Noskin, G.A. (2012) Rotavirus in Adults Requiring Hospitalization. Journal of Infection, 64, 89-95. http://www.ncbi.nlm.nih.gov/pubmed/21939687 http://dx.doi.org/10.1016/j.jinf.2011.09.003
[19]
Oyofo, B.A., Subekti, D., Tjaniadi, P., Machpud, N., Komalarini, S., Setiawan, B., Simanjuntak, C., Punjabi, N., Corwin, A.L., Wasfy, M., Campbell, J.R. and Lesmana, M. (2002) Enteropathogens Associated with Acute Diarrhea in Community and Hospital Patients in Jakarta, Indonesia. FEMS Immunology and Medical Microbiology, 34, 139-146. http://www.ncbi.nlm.nih.gov/pubmed/12381465 http://dx.doi.org/10.1111/j.1574-695X.2002.tb00615.x
[20]
del Refugio Gonzalez-Losa, M., Polanco-Marin, G.G., Manzano-Cabrera, L. and Puerto-Solis, M. (2001) Acute Gastroenteritis Associated with Rotavirus in Adults. Archives of Medical Research, 32, 164-167. http://www.ncbi.nlm.nih.gov/pubmed/11343816 http://dx.doi.org/10.1016/S0188-4409(00)00270-8
[21]
Das, S., Varghese, V., Chaudhury, S., Barman, P., Mahapatra, S., Kojima, K., Bhattacharya, S.K., Krishnan, T., Ratho, R.K., Chhotray, G.P., Phukan, A.C., Kobayashi, N. and Naik, T.N. (2003) Emergence of Novel Human Group A Rotavirus G12 Strains in India. Journal of Clinical Microbiology, 41, 2760-2762. http://www.ncbi.nlm.nih.gov/pubmed/12791925 http://dx.doi.org/10.1128/jcm.41.6.2760-2762.2003
[22]
Rahman, M., Sultana, R., Ahmed, G., Nahar, S., Hassan, Z.M., Saiada, F., Podder, G., Faruque, A.S., Siddique, A.K., Sack, D.A., Matthijnssens, J., Van Ranst, M. and Azim, T. (2007) Prevalence of G2P[4] and G12P[6] Rotavirus, Bangladesh. Emerging Infectious Diseases, 13, 18-24. http://www.ncbi.nlm.nih.gov/pubmed/17370511 http://dx.doi.org/10.3201/eid1301.060910
[23]
Alam, M.M., Malik, S.A., Shaukat, S., Naeem, A., Sharif, S., Angez, M., Rana, M.S., Khurshid, A. and Zaidi, S.Z. (2009) Genetic Characterization of Rotavirus Subtypes in Pakistan-First Report of G12 Genotype from Pakistan under WHO-Eastern Mediterranean Region. Virus Research, 144, 280-284. http://www.ncbi.nlm.nih.gov/pubmed/19720243 http://dx.doi.org/10.1016/j.virusres.2009.03.015
[24]
Ahmed, K., Batuwanthudawe, R., Chandrasena, T.G., Mitui, M.T., Rajindrajith, S., Galagoda, G., Pun, S.B., Uchida, R., Kunii, O., Moji, K., Abeysinghe, N., Nishizono, A. and Nakagomi, O. (2010) Rotavirus Infections with Multiple Emerging Genotypes in Sri Lanka. Archives of Virology, 155, 71-75. http://www.ncbi.nlm.nih.gov/pubmed/19921392 http://dx.doi.org/10.1007/s00705-009-0552-0
[25]
Sherchand, J.B., Nakagomi, O., Dove, W., Nakagomi, T., Yokoo, M., Pandey, B.D., Cuevas, L.E., Hart, C.A. and Cunliffe, N.A. (2009) Molecular Epidemiology of Rotavirus Diarrhea among Children Aged <5 Years in Nepal: Predominance of Emergent G12 Strains during 2 Years. The Journal of Infectious Diseases, 200, S182-S187. http://www.ncbi.nlm.nih.gov/pubmed/19817599 http://dx.doi.org/10.1086/605046
[26]
Gauchan, P., Nakagomi, T., Sherchand, J.B., Yokoo, M., Pandey, B.D., Cunliffe, N.A. and Nakagomi, O. (2013) Continued Circulation of G12P[6] Rotaviruses over 28 Months in Nepal: Successive Replacement of Predominant Strains. Tropical Medicine and Health, 41, 7-12. http://www.ncbi.nlm.nih.gov/pubmed/23533063 http://dx.doi.org/10.2149/tmh.2012-28
[27]
Kawai, K., O’Brien, M.A., Goveia, M.G., Mast, T.C. and El Khoury, A.C. (2012) Burden of Rotavirus Gastroenteritis and Distribution of Rotavirus Strains in Asia: A Systematic Review. Vaccine, 30, 1244-1254. http://www.ncbi.nlm.nih.gov/pubmed/22212128 http://dx.doi.org/10.1016/j.vaccine.2011.12.092
