Group A rotavirus (RVA) is the primary cause of acute gastroenteritis in children < 5 years of age worldwide. An estimated 453,000 children aged < 5 years die of RVA diarrhea each year, with > 85% of these deaths occurring in low-income countries.1,2 In Latin America and the Caribbean, RVA-associated gastroenteritis is responsible for an estimated 15,000 deaths, 75,000 hospitalizations, and 2 million clinic visits annually among children < 5 years of age.3 In Haiti alone, RVA causes an estimated 2,234 deaths annually among children < 5 years.4
After two safe and effective RVA vaccines became available, the World Health Organization (WHO) in 2007 recommended inclusion of RVA vaccine in the immunization programs of Europe and the Americas, and in 2009 expanded the recommendation to all infants < 32 weeks of age worldwide.5 Most Global Accelerated Vaccine Initiative (GAVI)–eligible countries in the Latin America and Caribbean have introduced RVA vaccines in their national immunization programs.3 In 2014, Haiti became the 14th GAVI-eligible, and last of five GAVI-eligible countries in the Latin American and Caribbean region, to introduce RVA vaccines in its national immunization program (PATH; www.path.org). Recent reports from these countries show significant declines in hospitalizations and deaths due to RVA and that these vaccines are safe and effective against severe RVA disease as well as a cost-effective intervention.3,6–8
The high estimated burden of RVA disease in Haitian children, together with the effectiveness of RVA vaccines to prevent childhood deaths and hospitalizations, accentuates the need for Haiti's introduction of RVA vaccines to save children's lives. Baseline data on the genotypes of circulating RVA strains in Haiti do not exist currently. We report results of molecular characterization of RVA strains collected as part of a laboratory-based surveillance for diarrheal diseases.
Beginning in April 2012, four geographically diverse hospitals participated in laboratory-enhanced surveillance for diarrheal diseases in Haiti, as has been described previously and continues to date.9 Each hospital collected and transported whole stool specimens from hospitalized patients with acute diarrhea (maximum 15 specimens per week) to the National Public Health Laboratory (NPHL). For the purposes of the surveillance, acute diarrhea was defined as three or more episodes of acute watery diarrhea within 24 hours, with onset of symptoms within the past 7 days. Specimens received at the NPHL were tested for RVA using Premier™ Rotaclone® (Meridian Diagnostics, Cincinnati, OH) enzyme immunoassay (EIA).9 Of the 392 specimens received at NPHL in April–June 2012, 200 were available for further analysis and shipped to the Rotavirus Surveillance Laboratory, U.S. Centers for Disease Control and Prevention (CDC) for further characterization. Of the 200 specimens, 38 were known to be from children < 5 years of age.
At the CDC, ribonucleic acid (RNA) was extracted from the 200 samples and tested for RVA using a NSP3 real-time reverse transcription polymerase chain reaction (qRT-PCR).10 Using the same RNA extracts, VP7 and VP4 genotyping was attempted on all RVA-positive samples using previously described protocols.11
Overall, 5/200 (2.5%) specimens were positive by RotaClone EIA, and 14 (7%) specimens, including the five RotaClone-positive specimens, were positive by the qRT-PCR assay. These results corroborate the generally accepted concept that molecular techniques are more sensitive than immunoassays. The low prevalence of RVA in the present study may be attributed, in part, to two factors: the low percentage of children enrolled in this study (only 19% of samples were known to be from children < 5 years of age) and the fact that most samples were collected during the rainy season. The typical peak season for RVA disease in tropical countries is during the dry season (which is typically December to March in Haiti).12 During a full year of RVA sentinel surveillance in Haiti,9 among patients with acute watery diarrhea, RVA was found in 13.5% of specimens from children < 5 years, 3.9% from children 5–18 years, and < 1% from persons > 18 years of age.
Out of the 14 qRT-PCR-positive samples, partial or complete G and P genotype could be assigned for 13 samples; two samples were G and P non-typeable (Table 1). G1P[8] was detected in 4/14 (28.6%) specimens followed by G9P[8] which was detected in 3/14 samples (21.4%). We also detected single cases of G2P[8], G12P[6], G12P[8], G2P[NT], and G1P[NT] (NT = non-typeable) (Table 1). Studies based on the molecular characterization of RVA into G and P genotypes in the Caribbean are scarce. However, similar to our findings in Haiti, the Dominican Republic,13,14 St. Vincent,15 and Cuba16 have all reported G1P[8] as the most common strain in circulation, followed by G9P[8]. The detection of genotype G12 for the first time in Haiti further confirms the emergence of this genotype globally.17
Rotavirus genotyping results for real-time RT-PCR positive samples
| Sample no. | Sampling date | Rotavirus EIA result | Approximate age | Rotavirus result real-time RT-PCR result | Genotype |
|---|---|---|---|---|---|
| 1 | 24/04/2012 | Not tested | 31 years | Positive | G1P[8] |
| 2 | 24/04/2012 | Positive | 20 months | Positive | G9P[8] |
| 3 | 3/05/2012 | Negative | 26 years | Positive | G1P[8] |
| 4 | 3/05/2012 | Negative | 9 years | Positive | G2P[NT] |
| 5 | 26/04/2012 | Negative | 35 years | Positive | GNTP[NT] |
| 6 | 30/04/2012 | Positive | 20 months | Positive | G1P[8] |
| 7 | 30/04/2012 | Negative | 30 years | Positive | G12P[8] |
| 8 | 27/04/2012 | Positive | 6 years | Positive | G1P[8] |
| 9 | 8/05/2012 | Negative | 20 years | Positive | G2P[8] |
| 10 | 9/05/2012 | Positive | 5 months | Positive | GNTP[NT] |
| 11 | 21/05/2012 | Not tested | 48 years | Positive | G12P[6] |
| 12 | Unknown | Negative | 30 years | Positive | G1P[NT] |
| 13 | Unknown | Negative | Unknown | Positive | G9P[8] |
| 14 | Unknown | Positive | 20 years | Positive | G9P[8] |
NT = non-typeable; RT-PCR = reverse transcription polymerase chain reaction.
One important limitation of this study was that the number of samples tested and genotyped was small. Given that vaccination against RVA has begun in Haiti, it now may be difficult to obtain a complete picture of RVA strain types in Haiti pre-vaccine introduction unless one has access to an archived sample collection. In the early stages of vaccine introduction when vaccine coverage is low, more extensive studies may still be useful to assess the impact of the vaccine on genotype distribution.
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