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A Correlational study between Nutritional Status and Severity of Rotavirus Diarrhea in children under five years in Bandung, Indonesia

Yudith Setiati Ermaya, Dwi Prasetyo, Iesje Martiza Sabaroedin, Yati Soenarto

Yudith Setiati Ermaya, MD Pediatrician: Department of Child Health, Faculty of Medicine Universitas Padjadjaran, Dr. Hasan Sadikin General Hospital, Bandung, West Java, Indonesia
Dwi Prasetyo, MD, PhD, Pediatrician, Consultant of Gastrohepatology, Department of Child Health, Faculty of Medicine Universitas Padjadjaran, Dr. Hasan Sadikin General Hospital, Bandung, West Java, Indonesia
Iesje Martiza Sabaroedin, MD, Pediatrician, Consultant of Gastrohepatology: Department of Child Health, Faculty of Medicine Universitas Pajadjaran, Dr. Hasan Sadikin General Hospital, Bandung, West Java, Indonesia
Yati Soenarto, Professor, MD, MSc, PhD, Pediatrician, Consultant of Gastrohepatology, Professor from Departments of Child Health and Microbiology, Faculty of Medicine, Gadjah Mada University, Sardjito Hospital, Yogyakarta, Indonesia

Conflict-of-interest statement: The author(s) declare(s) that there is no conflict of interest regarding the publication of this paper.

Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http: //creativecommons.org/licenses/by-nc/4.0/

Correspondence to: Yudith Setiati Ermaya, MD, Pediatrician, Department of Child Health, Faculty of Medicine Universitas Padjadjaran, Dr. Hasan Sadikin General Hospital, Bandung, West Java, Indonesia.
Email: udiths2016@gmail.com
Telephone: +62-022-2035957
Fax: +62-022-2035957

Received: August 19, 2016
Revised: April 10, 2017
Accepted: April 17, 2017
Published online: December 21, 2017

ABSTRACT

AIM: Diarrhea disease is a major cause of poor nutritional status in children. Malnutrition can make a person more susceptible to infection that also contributes to malnutrition, causing a vicious cycle. Surveillance of children hospitalized for diarrhea in 3 Indonesian hospitals found 60% were rotavirus positive and 41% were positive in outpatient clinics. The aim of this study was to measure the correlation of nutritional status with severity of rotavirus diarrhea.

MATERIALS AND METHODS: This study uses cross sectional design and included all children under 5 years old, both inpatients and outpatients, who presented with acute diarrhea at Dr. Hasan Sadikin General Hospital from January 2009 through December 2012. The Vesikari Clinical Severity Scoring System was considered the measurement for severe rotavirus diarrhea. Assessment of nutritional status used anthropometric weight for height from World Health Organization (WHO) child growth standards. Categorical data were analyzed by Pearson Chi square test.

RESULTS: Among 427 children aged 1-59 months, with rotavirus seropositive stool specimens, there were 258 (60%) boys and 169 (40%) girls. Nutritional status included “well nourished” (74%), “moderately malnourished” (23%) and “severely malnourished” (3%), while the distribution of severity for rotavirus diarrhea was “mild” (10%), “moderate” (21%) and “severe” (69%). This study showed that nutritional status had no significant correlation with severity of rotavirus diarrhea, p = 0.524.

CONCLUSIONS: Nutritional status had no significant correlation with severity of rotavirus diarrhea.

Key words: Children; Nutritional status; Severity rotavirus diarrhea

© 2017 The Author(s). Published by ACT Publishing Group Ltd. All rights reserved.

Ermaya YS, Prasetyo D, Sabaroedin IM, Soenarto Y. A Correlational study between Nutritional Status and Severity of Rotavirus Diarrhea in children under five years in Bandung, Indonesia. Journal of Gastroenterology and Hepatology Research 2017; 6(6): 2490-2094 Available from: URL: http://www.ghrnet.org/index.php/joghr/article/view/1816

INTRODUCTION

Diarrheal disease is a major cause of poor nutritional status in children[1]. Diarrhea is the second leading cause of death among children under the age of 5, resulting in one in 9 child deaths worldwide[2]. The mortality rate for children under five suffering from acute diarrhea has fallen from 4.5 million deaths annually in 1979 to 1.6 million deaths in 2002. In developing countries acute diarrhea continues to take a high toll on children; major causes of death among children under five include diarrhea (15%) and deaths associated with malnutrition (54%)[3]. Malnutrition is frequently part of a vicious cycle that includes disease and poverty. Malnutrition in children is the consequence of a range of factors that include insufficient food intake, often related to poor food quality, and severe and repeated infectious diseases, or frequently some combinations of the three[4]. Malnutrition can make a person more susceptible to infection that contributes to malnutrition, causing a vicious cycle[5]. A surveillance study in three Indonesian hospitals found that 60% of children hospitalized for diarrhea and 41% of children in outpatient clinics were rotavirus positive[6]. Rotavirus was detected in 47.8% of surveillance samples in Bandung (Indonesia)[7]. In tropical countries rotavirus is found year-round[8].

The rotavirus infection in association with malnutrition may cause a significant rise in gut permeability to environmental macromolecules, a combination that results in more severe mucosal damage, including disruption of the microvillus border[9]. Infection adversely affects nutritional status through increased catabolism, reductions in dietary intake, and intestinal absorption and sequestration of nutrients that are required for tissue synthesis and growth[10]. Poor appetite, vomiting, deliberate with holding of food resulting in poor intake; malabsorption of macro and micronutrients; hastening of intestinal transit time; disturbance of metabolic and endocrine functions; and direct loss of protein and other nutrients in gastrointestinal tract are some of the known mechanisms which have an impact on nutrition during an episode of diarrhea[1].

Rotavirus is a leading cause of severe acute diarrhea requiring hospitalization among infants and young children worldwide[11]. Severe acute malnutrition in Kenyan children, complicated by diarrhea, had a higher risk of death than those who did not have diarrhea during their hospital stay[12]. In particular, promotion of breastfeeding to prevent diarrhea and reduce its nutritional complications, as well as continued feeding during illness and supplementation with selected micronutrients, both to prevent enteric infections and to reduce their severity, are all important to control diarrheal diseases and their associated nutritional complications[10]. In rotavirus diarrhea, however, there was no significant association between exclusive breastfeeding and severe dehydration[13].

The aim of this study was to measure the correlation of nutritional status with severity of rotavirus diarrhea among young children.

Methods

This study used cross sectional design and included all children under 5 years old (U5) inpatients and outpatients who presented with acute diarrhea at Dr. Hasan Sadikin General Hospital, Bandung, West Java, Indonesia, from January 2009 through December 2012. A fresh fecal specimen was obtained from enrolled children within 24 hours after admission and was stored at 4°C-8°C before being tested at the Laboratory of Microbiology using Pro Spec TTM Rotavirus microplate assay as the Rota antigen agent of detection.

For this study diarrhea was defined as three or more abnormally loose or watery stools during the previous 24 hours. This analysis used the Vesikari Clinical Severity Scoring System to assess the severity for diarrhea caused by Rotavirus. System parameters take into account each of the important symptoms identified in the clinical presentation profile: diarrhea, vomiting, fever, dehydration, and the duration of diarrhea and vomiting. An additional parameter considered is treatment status. There are seven scoring parameters (Table 1) included in the Vesikari Clinical Severity Scoring System (Table 2) [14]. The Vesikari assessment is currently considered the best measurement for severe rotavirus diarrhea.

Table 1 Vesikari Clinical Severity Scoring System Parameters and Scores
ParameterScore
123
Diarrhea
Maximum Number Stools per Day 1 - 3 4 - 5≥ 6
Diarrhea Duration (Day) 1 - 45≥ 6
Vomiting
Maximum Number Vomiting per Day1 2 - 4≥ 5
Vomiting Duration (Day)12≥ 3
Temperature 37.1 - 38.4 38.5 - 38.9≥ 39.0
DehydrationN/A1-5%≥ 6%
TreatmentRehydrationHospitalizationN/A

Table 2 Vesikari Severity Category
Severity Category
MildModerateSevereMaximum score
< 7 7 - 10≥ 1120

Nutritional status was assessed with WHO child growth standards, specifically weight-for-height. Length of infant sand children under 24 months of age was measured lying down (supine). Height of children over 24 months of age was measured while standing. For simplicity, however, infants and children under 87 cm was measured lying down (or supine) and those above 87 cm standing. Malnutrition was defined as “well nourished” (no wasting) “moderately malnourished” (weight-for-heights score [WHZ] < -2.00SD), and “severely malnourished” < -3.00 SD[4,15]. These anthropometric WHO child growth standards are a measure of SDs above or below the median for the international reference population. The deviation of an individual’s value from the median value of a reference population, divided by the standard deviation of the reference population[4,15].

Independent variables used in this analysis included sex, age, nutritional status, clinical manifestation of diarrhea, fever, dehydration status, and hospitalization. The severity of dehydration was assessed according to the WHO Integrated Management of diarrhea and categorized into “severe”, “some”, or “no dehydration”[16]. Patients without any signs of dehydration were considered assess with mild disease (no dehydration). Moderate or some dehydration was defined as one or more of the following signs: restlessness, irritability, sunken eyes, drinking eagerly, thirsty, and skin pinch goes backs lowly. Severe dehydration was defined as two or more of the following signs: lethargy or un consciousness, sunken eyes, drinks poorly or not able to drink, and skin pinch goes back very slowly (>2 seconds)[16]. This study was approved by the Ethical Committee.

Statistical analysis

Data were expressed as sums and percentages. The correlation of severity of rotavirus diarrhea and nutritional status was analyzed by Pearson Chi square test and values of < 0.05 were considered statistically significant. Data was analyzed using Epi Info v.3.5.4.

Results

In the 4-year period from January 2009 through December 2012, there were 945 children with hospital admissions aged 1-59 months for acute diarrhea at Dr. Hasan Sadikin General Hospital, 427 (45%) of these patients were rotavirus positive and included in this study. There were 258 (60%) boys and 169 (40%) girls. We found that most children were well-nourished (74%), followed by moderately malnourished (23%), and a small group suffered severe acute malnutrition (3%). Children admitted for diarrhea showed year-round distribution for hospital admission with an annual peak in January. The severity scores of rotavirus diarrhea were most commonly severe (69%), followed by moderate (21%), and mild (10%). We observed that more patients with rotavirus diarrhea were admitted to the hospital (62%), and among these, more had “severe” diarrhea (80.4%). Severe diarrhea was more common among male infants between 1 and 24 months of age. Among patients with severe diarrhea, most were well-nourished (normal) and presented with vomiting but no fever. These patients also showed signs of dehydration and were more often admitted to the hospital. Severity of rotavirus diarrhea had no significant correlation with sex, age, nutritional status, and fever (Table 3). Conversely, vomiting, dehydration and hospitalization had significant correlation with severity of rotavirus diarrhea (Table 3).

After examining hospitalization status, outpatients showed no significant correlation between severity of rotavirus diarrhea and either dehydration nor nutrition status (Table 4). Inpatients, however, showed a significant correlation with dehydration status. Vomiting was significantly associated with severe diarrhea in both outpatients and inpatients.

Table 3 Correlation of Nutritional Status with Severity of Rotavirus Diarrhea
Variablesn (%)Severity of Diarrhea Rotavirusp-value*
Mild (<7)Moderate (7-10) Severe (≥ 11)
n=43 (10) n=91 (21) n=293 (69)
Sex
Boys258 (60)25 (9.7)51 (19.8)182 (70.5)0.556
Girls169 (40)18 (10.6)40(23.7)111 (65.7) 
Age (months)
1 ≤ 24 month386 (90)38 (9.8)81 (21.0)267 (69.2)0.747
>24 - 59 month 41 (10)5 (12.2)10 (24.4)26(63.4) 
Nutritional status
Well-nourished(normal) 317 (74) 30 (9.5) 73 (23.0) 214 (67.5)0.524
Moderately malnourished 98 (23) 12 (12.2) 17 (17.4) 69 (70.4) 
Severely malnourished 12 (3) 1 (8.3) 1(8.3) 10 (83.4) 
Clinical Manifestation
Vomiting 327 (77) 4 (1.2) 39(11.9) 284 (86.9) <0.001
Without vomiting 100 (33) 39 (39.0) 52 (52.0) 9 (9.0) 
Fever
<37.5 °C 249 (58) 29 (11.6) 53 (21.3) 167 (67.1) 0.324
37.5-38.5 °C 126 (30) 13 (10.3)27 (21.4)86 (68.3) 
>38.5 °C 52 (12) 1 (1.9) 11 (21.2) 40 (76.9) 
Dehydration
No Dehydration 171 (40) 35 (20.4) 48 (28.1) 88 (51.5) <0.001
Some Dehydration 230 (54) 7 (3.0) 41 (17.8) 182 (79.1) 
Severe Dehydration 26 (6) 1 (3.8) 2 (7.7) 23 (88.5) 
Hospitalization
Outpatient162(38) 31 (19.1)51 (31.5)80 (49.4) <0.001
Inpatient265(62) 12 (4.5)40 (15.1) 213 (80.4)  

Table 4 Correlation of Hospitalization Status with Nutritional Status and Severity of Rotavirus Diarrhea
VariableSeverity of Diarrhea Rotavirus*p value
Hospitalization StatusClinical Manifestation  MildModerateSevere
n =427n=43 (10)n=91 (21)n=293 (69)
OutpatientWithout vomiting4528 (62.2)16 (35.6)1( 2.2)<0.001
Vomiting1173 (2.6)35 (29.9)79 (67.5) 
No Dehydration 9024 (267)28 (31.1)38 (42.2)0.065
Some Dehydration717 (9.9)23 (32.4)41 (57.7) 
Severe Dehydration10 (0)0 (0)1 (100) 
Well-nourished(normal)12224 (19.7)43 (35.2)55 (45.1)0.227
Moderately malnourished386 (15.8)8 (21.1)24 (63.1) 
Severely malnourished21 (50)0 (0)1 (50) 
InpatientWithout vomiting5511 (20)36 (65.5)8 (14.5)<0.001
Vomiting2101 (0.5)4 (1.9)205 (97.6) 
No Dehydration 8111 (13.6)20 (24.7)50 (61.7)<0.001
Some Dehydration1590 (0)18 (11.3)141 (88.7) 
Severe Dehydration251 (4.0)2 (8.0)22 (88.0) 
Well-nourished(normal)1956 (3.1)30 (15.4)159 (81.5)0.209
Moderately malnourished606 (10)9 (15)45 (75) 
Severely malnourished 100 (0)1 (10)9 (90) 
*Pearson chi square test.

DISCUSSION

Our study showed a rotavirus prevalence of 45% in children with diarrhea attending the Dr. Hasan Sadikin General Hospital. Similar results for rotavirus prevalence were obtained from a related study from Ahmed et al[17].

We found rotavirus diarrhea predominantly in male children (60%), which is also quite similar to other studies[17,18]. However, as in our study, no significant correlation of gender with severity of rotavirus diarrhea was evident in previous studies[19,20].

Our study found the number of children less than 2 years of age infected with rotavirus was nine times greater than among children aged 2 to 5 years; however, age showed no significant correlation with severity of rotavirus diarrhea. This result is similar to the findings of studies from Ahmed et al and Nitiema et al[17,21].

One quarter of the children in our study presenting with rotavirus diarrhea also suffered from malnutrition. A previous study by Talbert et al shows that diarrhea is a common complication (49%) in children hospitalized with severe acute malnutrition[12]. It is known that malnutrition affects severity of diarrhea much more than it affects incidence of diarrhea. Another study showed the risk of diarrhea was 19.80% in normal participants and 27.45% in undernourished children[22]. The clinical severity score for diarrhea was greater with malnutrition for all malnutrition indicators, status nutrition in this study no significant correlation with severity of rotavirus diarrhea.

The distribution of severity of rotavirus diarrhea in our study where more than two-thirds of patients had “severe” scores is similar to other studies. Ibrahim et al also reported among rotavirus positive cases, 56% had severe scores, 32% had moderate scores moderate scores and 12 % had mild scores[20].

In this study, clinical manifestations such as frequent vomiting were common (77%), and this might contribute to the higher proportion of diarrhea associated with moderate or severe dehydration (60%). Vomiting and dehydration are significantly correlated with severity of rotavirus diarrhea in our study, and previous studies also reported similar findings[23]. Among children with rotavirus diarrhea, the number presenting with and without a fever was similar to that found by Saker et al[24]. Fever showed no significant correlation with severity of rotavirus diarrhea. This result was comparable to that of Ibrahim et al[20].

The significant correlation between patient hospitalization status and the severity of rotavirus diarrhea in our study, perhaps related to the longer duration of the illness, was also found in a study from García Roig et al[23]. This is consistent with a study by Mathew et al that found rotavirus positive patients accounted for 35.9% of diarrhea-related hospitalizations among children less than 5 years of age[25]. Khagayi et al. reported the cumulative risk of rotavirus hospitalizations by 5 years of age as 1 in 40[18].

In conclusion, our study found that nutritional status had no significant correlation with the severity of rotavirus diarrhea in young children.

Acknowledgement

The authors wish to acknowledge The Laboratory of Microbiology, Gadjah Mada University.

REFERENCES

1. Patwari AK. Diarrhea and malnutrition interaction. Indian J Pediatr. 1999; 66 Suppl 1: S124-134. [PMID: 11132459]

2. Centers for Disease Control and Prevention Diarrhea: Common illness, global killer. Atlanta: Centers for Disease Control and Prevention, 2015; online 2015-12-17, cited 2015-12-30. [Link]

3. WHO,UNICEF. Joint Statement on Clinical Management of Acute Diarrhoea. New York, UNICEF, 2004; online pdf, 2014-05-01, cited 2015-03-10. [Link]

4. Onis M, Blössner M. WHO global database on child growth and malnutrition. Programme of nutrition 1997, cited 2015-04-26: 67 screens. [Link]

5. Katona P, Kantona-Apte J. The interaction between nutrition and infection. Cid Clinical Practice. 2008; 46:1582-1588. [PMID: 18419494]; [DOI: 10.1086/587658]

6. Soenarto Y1, Aman AT, Bakri A, Waluya H, Firmansyah A, Kadim M, Martiza I, Prasetyo D, Mulyani NS, Widowati T, Soetjiningsih, Karyana IP, Sukardi W, Bresee J, Widdowson MA. Burden of severe rotavirus diarrhea in Indonesia. JID. 2009; 20: 188-194. [PMID: 19821711]; [DOI: 10.1086/605338]

7. Prasetyo D, Ermaya Y, Martiza I, Yati S. Correlation between climate variations and rotavirus diarrhea in under-five children in Bandung. Asian Pac J Trop Dis. 2015; 5(11): 908-911. [DOI: 10.1016/S2222-1808(15)60955-0]

8. Prasetyo D, Martiza I, Soenarto Y. Surveillance of rotavirus diarrhea in Dr. Hasan Sadikin general hospital Bandung. MKB. 2010; 42(4): 155-160. [DOI: 10.15395/ mkb.v42n4.29]

9. Uhnoo IS, Freihorst J, Ripenhoff-Talty M, Fisher JE, Ogra PL. Effect of rotavirus infection and malnutrition on uptake of a dietary antigen in the intestine. Pediatr Res. 1990; 27(2): 153-160. [PMID: 2314944]; [DOI: 10.1203/00006450-199002000-00014]

10. Brown KH. Diarrhea and malnutrition. J Nutr. 2003; 133 (1: 328S-332S. [PMID: 12514320]

11. Agócs MM, Serhan F, Yen C, Mwenda JM, Oliveira LHd, Teleb N, Wasley A, Wijesinghe PR, Fox K, E. Tate JE, Gentsch JR, Parashar UD, Kang G. WHO global rotavirus surveillance network: a strategic review of the first 5 years. MMWR Morb Mortal Wkly Rep. 2014; 63(29): 634-637. [PMID: 25055187]

12. Talbert A, Thuo N, Karisa J, Chesaro C, Ohuma E, Ignas J, Berkley JA, Toromo C, Atkinson S, Maitland K. Diarrhoea complicating severe acute malnutrition in Kenyan children: a prospective descriptive study of risk factors and outcome. PLoS One. 2012; 7(6): e38321. [PMID: 22675542]; [PMCID: PMC3366921]; [DOI: 10.1371/ journal.pone.0038321]

13. Prasetyo D, Sabaroedin IM, Ermaya YS, Soenarto Y. Association between Severe Dehydration in Rotavirus Diarrhea and Exclusive Breastfeeding among Infants at Dr. Hasan Sadikin General Hospital, Bandung, Indonesia. J Trop Med. 2015;2015:862578 [PMID: 26612990]; [PMCID: PMC4647027]; [DOI: 10.1155/2015/862578]

14. Lewis K. Vesikari clinical severity scoring system manual. PATH Publications, 2011: 3-17

15. World Health Organization and UNICEF. WHO Child Growth Standards and the Identification of Severe Acute Malnutrition in Infants and Children. A Joint Statement by the World Health Organization and the United Nations Children’s Fund. Geneva: WHO Press, 2009: 2-11. [PMID: 24809116]; [ISBN 978 92 4 159816 3]

16. World Health Organization. The treatment of diarrhea: A manual for physicians and other senior health workers. Geneva: WHO Press, 2005: 6-28. [Link]

17. Ahmed S, Kabir L, Rahan A, Hussain M, Khatoon S, Hannan A. Severity of rotavirus diarrhea in children: one year experience in a children hospital of Bangladesh. Iran J Pediatr. 2009; 19(2): 108-116. [ID=pe09017]

18. Khagayi S, Burton DC, Onkoba R, Ochieng B, Ismail A, Mutonga D, Muthoni J, Feikin DR, Breiman RF, Mwenda JM, Odhiambo F, Laserson KF High burden of rotavirus gastroenteritis in young children in rural western Kenya, 2010-2011. Pediatr Infect Dis J. 2014; 33 Suppl 1: S34-40. [PMID: 24343611]; [DOI: 10.1097/INF.0000000000000 049]

19. Ferdous F, Das SK, Ahmed S, Farzana FD, Latham JR, Chisti MJ, Ud-Din AI, Azmi IJ, Talukder KA, Faruque AS. Severity of diarrhea and malnutrition among under five-year-old children in rural Bangladesh. Am J Trop Med Hyg. 2013; 89(2): 223-228. [PMID: 23817334]; [PMCID: PMC3741240]; [DOI: 10.4269/ajtmh.12-0743]

20. Ibrahim SB, El-Bialy AA, Mohammed MS, El-Sheikh AO, Elhewala A, Bahgat S. Detection of Rotavirus in children with acute gastroenteritis in Zagazig University Hospitals in Egypt. Electron Physician. 2015; 7(5): 1227-1233. [PMID: 26435821]; [PMCID: PMC4590557]; [DOI: 10.14661/1227]

21. Nitiema LW, Nordgren J, Ouermi D, Dianou D, Traore AS, Svensson L, Simpore J. Burden of rotavirus and other enteropathogens among children with diarrhea in Burkina Faso. Int J Infect Dis. 2011; 15(9): e646-652. [PMID: 21763172]; [DOI: 10.1016/j.ijid.2011.05.009]

22. Gupta A, Sarker G, Rout AJ, Mondal T, Pal R. Risk correlates of diarrhea in children under 5 years of age in slums of bankura, west bengal. J Glob Infect Dis. 2015; 7(1): 23-29. [PMID: 25722616]; [PMCID: PMC4338445]; [DOI: 10.4103/0974-777X.150887]

23. García Roig C, Larre N, Pastene H, Gutiérrez L, Vaccaro J, Sciarrotta JA, Lepetic A, Moreno C, Ellis A. Epidemiological and clinical characteristics of acute gastroenteritis according to their etiology (rotavirus or other) in children younger than 5 years old at a private institution in the city of Buenos Aires. Arch Argent Pediatr. 2013;111(3): 218-223. [PMID: 23732348]; [DOI: 10.5546/aap.2013.218]

24. Sarker MH, Das SK, Ahmed S, Ferdous F, Das J, Farzana FD, Shahid AS, Shahunja KM, Afrad MH, Malek MA, Chisti MJ, Bardhan PK, Hossain MI, Al Mamun A, Faruque AS. Changing characteristics of rotavirus diarrhea in children younger than five years in urban Bangladesh. PLoS One. 2014; 9(8): e105978. [PMID: 25171098]; [PMCID: PMC4149481]; [DOI: 10.1371/journal.pone.0105978]

25. Mathew MA1, Paulose A, Chitralekha S, Nair MK, Kang G, Kilgore P. Prevalence of rotavirus diarrhea among hospitalized under-five children. Indian Pediatr. 2014; 51(1): 27-31. [PMID: 24277960]

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