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 Table of Contents  
Year : 2017  |  Volume : 1  |  Issue : 3  |  Page : 76-79

Frequency of rota virus infection among children in North-Eastern Region of Libya: A hospital-based study from Almarj

1 Department of Surveillance and Response, Public Health Administration, Ministry of Health, Al Khoms, Libya
2 Department of Public Health, Medical Technology College, Elmergib University, Al Khoms, Libya
3 Department of Epidemiology and Biostatistics, Mel and Enid Zuckerman College of Public Health, The University of Arizona, Tucson, Arizona, USA
4 Department of Community Medicine, Medicine College, University of Tripoli, Tripoli, Libya

Date of Web Publication26-Dec-2017

Correspondence Address:
Dr. Salem I.M Alkoshi
P O Box 504, Zliten City
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/LJMS.LJMS_17_17

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Background: Rotavirus causes a significant proportion of diarrheal disease among young children worldwide. However, there is limited knowledge about the epidemiology of rotavirus in Libya. This study aimed to quantify the burden of rotavirus diarrhea among children under age 5 years. Materials and Methods: A prospective cross-sectional study was conducted in Almarj city between January 2011 and March 2012. Stool samples were obtained and tested for rotavirus from children <5 years admitted to the main public hospital for diarrhea. Patients with rotavirus were characterized by clinical symptoms; duration of diarrhea, fever, vomiting, and dehydration. Analyses of positive rotavirus patients were further stratified by breastfed versus bottle-fed children. Results: Rotavirus accounted for 57.4% of 270 diarrhea cases admitted to Almarj hospital. Rotavirus cases were more likely to be younger than 1 year of age (74% in rotavirus positive). Rotavirus patients commonly had symptoms 6 days (65%), and presented with vomiting (69%), high fever was uncommon (13%), and 42% had a normal temperature. Dehydration was common; moderate dehydration was seen in 79% of patients and 12% were severely dehydrated. About 89% of children infected by rotavirus cases were fed by bottle. Conclusion: There is a high burden of rotavirus in Almerj city located in North-Eastern region of Libya. While breastfeeding is recommended to reduce risk; increasing coverage of the rotavirus vaccine in children is likely to be the most effective and cost-effective strategy.

Keywords: Children, diarrhea, Libya, rotavirus, vaccine

How to cite this article:
Miftah A, Alkoshi SI, Ernst KC, Nagib SM. Frequency of rota virus infection among children in North-Eastern Region of Libya: A hospital-based study from Almarj. Libyan J Med Sci 2017;1:76-9

How to cite this URL:
Miftah A, Alkoshi SI, Ernst KC, Nagib SM. Frequency of rota virus infection among children in North-Eastern Region of Libya: A hospital-based study from Almarj. Libyan J Med Sci [serial online] 2017 [cited 2022 Oct 7];1:76-9. Available from: https://www.ljmsonline.com/text.asp?2017/1/3/76/221493

  Introduction Top

Globally, more than 450,000 children under 5 years of age are still die from rotavirus infection each year, most of whom live in developing countries representing 5% of all death in children younger than five.[1] Rotavirus A, which accounts for more than 90% of rotavirus diarrhea in human, is endemic worldwide.[2] Rotavirus is the most common cause of severe diarrhea among infants and young children.[3],[4],[5] Nearly, every child in the world has been infected with rotavirus at least once by the age of five.[6] Symptomatic infection rates are highest in children under 2 years of age and decrease progressively until 45 years of age.[7] The most severe symptoms tend to occur in children 6 months to 2 years of age, the elderly, and those immune disorders.[8] Rotavirus presentation is nonspecific and clinical care involves management of symptoms including, most importantly, maintenance of hydration through oral rehydration of mild and moderate dehydration cases and intravenous rehydration for severe cases. If untreated, children can die from severe dehydration.[9],[10],[11]

Two vaccines against rotavirus A infection are safe and effective in children. Rotarix by Glaxo Smith Kline and Rota Teg by Merck.[12] Since 2006, rotavirus vaccination reduced rotavirus-related hospitalization by 86%.[13] Previous work in Libya, identified that rotavirus accounts for a substantial portion of diarrheal illness in young children.[14],[15] The vaccine has being given to all children in October 2013 in three doses (2 months, 4 months, and 6 months), with a coverage rate of 95.8% for first dose and 91.3% for third dose in 2015. The aim of this paper is to further identify the prevaccination burden of disease in Libyan children under 5 years of age residing in Almarj city which could represent the North-Eastern region of Libya, an area characterized by approximately two million population and limited data exist for proportion of rotavirus among young children, and to examine the potential role of breastfeeding on rotavirus positive cases of diarrheal illness.

  Materials and Methods Top

A prospective observational study of patients admitted to a public hospital in Almarj was conducted to determine the incidence and relative burden of rotavirus infection from January 2011 to March 2012. Almarj city is located in the North-Eastern region of Libya about 100 km north of Benghazi city. Almarj city is representative of the culture and lifestyle throughout Libya, making it an ideal location to determine the profile of rotaviral illness.

Study population and case definition

All cases with diarrhea aged <5 years admitted to the public hospital in Almarj city which has a catchment area of approximately 43.182 people according to 2010 population data.

Case detection

Stool samples were collected from cases that fit the definition (diarrhea cases) using the World Health Organization (WHO) standard operating procedures.[16] The samples were tested at the National Center for Disease Control (NCDC) laboratory for infectious diseases and at Benghazi pediatric hospital, which is one of rotavirus laboratories approved by NCDC. NCDC certified laboratories require laboratory personnel are trained for detection of rotaviruses. The kits used were recommended and supplied by the WHO. The laboratory used an enzyme immunoassay (ProSpect Rotavirus Test, Oxoid Ltd, UK) to detect Group A rotavirus. “The ProSpecT™ Rotavirus test is a qualitative enzyme immunoassay for the detection of rotavirus (Group A) in human fecal samples as an aid in the diagnosis of acute gastroenteritis. The test utilizes a polyclonal antibody to detect group-specific proteins, including the major inner capsid protein (VP6), present in Group A rotaviruses.”[17]

Data and samples collection

All children aged below 5 years having diarrhea symptoms who sought treatment at the pediatric ward during the study were identified to be included in the study. Diarrhea was defined as having three or more episodes of liquid stool daily. A stool sample was collected from each patient by a trained nurse. Additional data were extracted from medical records including age, symptoms (fever, vomiting, and dehydration status), duration of diarrhea patients, and history of feeding habit (breastfed and bottle-fed).

Data analysis

The data were analyzed using SPSS software to calculate rates of rotavirus diarrhea in children <5 years and to compare the profiles of diarrheal cases positive for rotavirus or another pathogen. Further comparisons were made by feeding type breastfed and bottle-fed and dehydration status.


Parents agreed and provided oral consent to their child's participation in the study. Ethical clearance was provided from Almarj hospital and NCDC to conduct the study.

  Results Top

Proportion of rotavirus

Over half, 155 out of 270 stool samples, were positive (57.4%) for rotavirus. Nearly, three-quarters of rotavirus-positive children were under the age of 1 year (114/155, 74%). A lower level was determined in the other age groups; 1–2-year-old made up 21% (33/155) of cases and 2–5 years only 5% (8/155). Diarrheal cases negative for rotavirus were slightly older; below 1-year-old (81/115, 70%), 1–2 years (20/115, 17%), and 2–5 years old (14/115, 12%), P = 0.101 [Table 1]. Individuals positive for rotavirus were from both urban (103/155, 66%) and rural areas (52/155), P = 0.931.
Table 1: Age distribution of rotavirus cases and nonrotavirus diarrheal illnesses

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Duration of diarrhea patients

The duration of diarrhea for positive rotavirus patients was more than 6 days in 100 patients (100/155, 65%), 4–5 days in 27 patients (27/155, 6%), and 3 days in 28 patients (28/155, 18%); while the most of negative rotavirus patients (71/115, 62%) had more than 6 days, while negative rotavirus patients had duration of study as 6 days and more for 71/115 (62%), 4–5 days for 26/115 (23%), and 3 days in 18/115 (16%), P = 0.546.

Fever and vomiting for diarrhea patients

Vomiting manifested in 69% of positive rotavirus patients but only 31% rotavirus negative diarrheal patients, P = 0.0002. Fever was high in 36/270 (13%) of diarrhea patients (positive and negative), moderate (37C–39C) in 120/270 (44%) of all diarrhea patients and normal fever in 114/270 (42%) cases. Fever in positive cases was slightly higher than negative cases, P = 0.951.

Dehydration status

Of all positive cases (155), severe dehydration was found in 19/155 (12%) patients, moderate dehydration in 122/155 (79%) patients, and 14/155 (9%) rotavirus patients had no dehydration. For rotavirus-negative diarrheal patients the dehydration status was slightly less severe (12/115, 10%), equally moderate (90/115, 78%), and no dehydration (13/115, 11%), P = 0.287.

Feeding of diarrhea patients

Feeding patterns for positive rotavirus cases were identified and categorized into bottle-fed (138/155, 89%), while positive rotavirus patients nurtured by breastfeed were very low (17/155, 11%), P = 0.587.

  Discussion Top

Rotavirus infection constituted over half of all diarrheal cases admitted to the regional hospital in children under 5. This is one of the first studies to demonstrate the proportion of diarrheal cases caused by rotavirus in Libya. This was higher than data reported to the NCDC between 2007 and 2009 which determined the burden of rotavirus was 44% of diarrhea cases aged <5 years.[18] However, this study was consistent with another regional study conducted in the northwestern region of Libya in 2012–2013; in which rotavirus caused 58% cases of hospital admitted diarrhea patients among children aged <5 years.[19] Two Libyan studies were conducted in Tripoli in 2008 and 2009 showed that rotavirus had burden as 31.5% and 33%, respectively. These studies had burden of rotavirus lower than this study which represented different region of Libya.[20],[21]

Compared to studies regionally and globally, Libya has one of the highest proportions of diarrheal illness caused by rotavirus. A comprehensive review determined that between 1980 and 2009, globally rotavirus diarrhea ranged between 24% and 45% of diarrheal cases. Compared to other countries in the Middle East and North Africa, the proportion of rotavirus in this study was higher than most including Saudi Arab 16% in 2005, Tunisia 23% in 2006, and Egypt 42% in 2007 although it was moderately lower than Syria (61% in 2007) and Iran (59% in 2007).[22] Comparing more broadly, the burden in Libya, is also high. Thailand is relatively high (48.2% in 2002), as are Bangladesh (41.8% in 2009) and India (49.9% in 2008) but other areas have substantially lower rates including Italy (27.6% in 2005) and Burkina Faso (33.8% in 2010).[23],[24],[25],[26],[27],[28]

Severe nature of dehydration often occurs in rotavirus cases. There is no surprising this study demonstrated severe dehydration in 12%, moderate dehydration in 79%, and no dehydration in 9% of positive rotavirus. A study conducted in North-west region of Libya showed that severe degree in positive rotavirus was higher (31% of) than this study, while moderate degree was lower (66%) than this study.[15]

Breastfeeding protects against rotavirus infection. In this study, we found very low rates of breastfeeding in the rotavirus cases (11%). This is similar to another study which found the percentage of breastfed cases to be significantly lower than those who with bottle-fed (14% vs. 50%).[29] In addition, hospitalization of positive rotavirus cases was lower for those who had a history of being breastfed. Breastfeeding in Libya in the general population is estimated at 89% of all Libyan children.[30]

In October 2013, rotavirus vaccine was introduced as a mandatory vaccine for all children in Libya. Since this study was conducted before that time, this study provides baseline information that can be used to evaluate the impact of rotavirus vaccine in future. Furthermore, the vaccine is regarded as cost-effective based on a study conducted in Libya in 2013.[31]

  Conclusion Top

Rotavirus represents a significant burden among children, which allow us to document prevaccine prevalence among hospitalized rotavirus children. Vaccine assessment will be critically important for making future comparisons in postvaccination studies. Nutrition habit could affect the burden of disease among young children.


We would express our gratitude to NCDC in Libya for providing permission to use the national laboratory to test the samples, and also we would thank all parents for the consent to process the study. The authors declare that there is no conflict of interests.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

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