BMJ Open19 Street, 546 38, Thessaloniki, Greece, 5Venizeleio Hospital, Pediatric Department, 346 ... 36 Interventions: None given for the purpose of the study. ... 112 developed acute

For peer review only

Burden of rotavirus gastroenteritis in children <5 years of age in Greece: Hospital-based prospective surveillance

(2008−2010)

Journal: BMJ Open

Manuscript ID: bmjopen-2013-003570

Article Type: Research

Date Submitted by the Author: 08-Jul-2013

Complete List of Authors: Konstantopoulos, Andreas Tragiannidis, Athanasios Fouzas, Sotirios

Kavaliotis, John Tsiatsou, Olga Michailidou, Elisa Spanaki, Ariana Mantagos, Stefanos Kafetzis, Dimitrios Papaevangelou, Vana Gopala, Kusuma Holl, Katsiaryna

<b>Primary Subject Heading</b>:

Infectious diseases

Secondary Subject Heading: Infectious diseases, Epidemiology

Keywords: INFECTIOUS DISEASES, Epidemiology < INFECTIOUS DISEASES, Public health < INFECTIOUS DISEASES

For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml

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Target journal: BMJ OPEN CONFIDENTIAL 8 July 2013

TITLE PAGE 1

Type: Original research 2

Manuscript Title: Burden of rotavirus gastroenteritis in children <5 years of age in 3

Greece: Hospital-based prospective surveillance (2008−2010) 4

Author(s): Konstantopoulos Andreas,1 Tragiannidis Athanasios,

2 Fouzas Sotirios,

3 5

Kavaliotis John,4 Tsiatsou Olga,

4 Michailidou Elisa,

4 Spanaki Ariana,

5 Mantagos 6

Stefanos,3 Kafetzis Dimitrios,

6 Papaevangelou Vana,

6 Gopala Kusuma,

7 Holl 7

Katsiaryna8 8

Corresponding author: Konstantopoulos Andreas 9

Address: 18 Kifissias Av. 125 26 Athens, Greece, 10

Email: [email protected] 11

Tel: +30 210 6383052 12

Fax: +30 210 6383054 13

Affiliations/Institutions: 1IASO Children’s hospital, 37-39 Kifissias Ave. 151 23 14

Maroussi Athens Greece, 2

AHEPA Hospital of Thessaloniki, 2nd

University Paediatric 15

Clinic, 1 St. Kyriakidis Street, 546 36, Thessaloniki, Greece, 3University Hospital of 16

Patras, Paediatric Clinic, P.E.O. Patras-Athens, 265 00, Rio, Patras, Greece, 4 17

Infectious Diseases Hospital of Thessaloniki, Paediatric Clinic, 13 G. Lambraki 18

Street, 546 38, Thessaloniki, Greece, 5

Venizeleio Hospital, Pediatric Department, 346 19

Knosou Avenue, 714 09, Heraklion, Crete, Greece, 6

Second Department of 20

Pediatrics, University of Athens, P. & A. Kyriakou Children; s Hospital, Athens 115 21

27 Greece, 7GlaxoSmithKline, Bangalore, India,

8GlaxoSmithKline Vaccines, Wavre, 22

Belgium 23

Keywords: acute gastroenteritis, rotavirus, Greece, nosocomial RVGE 24

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Word count: 2795/4000 25

ABSTRACT 26

Objectives: This study describes the epidemiology of rotavirus (RV) gastroenteritis 27

(GE) disease following introduction of RV vaccination in Greece in 2006. 28

Design: A prospective hospital-based surveillance. 29

Setting: A multi-center study was conducted at six hospitals in Greece between July 30

2008 and March 2010. The hospitals selected served 70% of the pediatric population 31

in Greece. 32

Participants: Children aged <5years who visited the emergency rooms (ER) or 33

hospitalized with acute GE, or acquired acute GE 48hours after hospitalization and 34

with a confirmed RV-positive stool test were enrolled. 35

Interventions: None given for the purpose of the study. 36

Primary and secondary outcome measures: Occurrence of RVGE among all acute 37

GE ER visits and hospitalizations and occurrence of nosocomial RVGE are reported 38

with 95% exact confidence interval (CI). Age-specific proportions of RVGE, 39

seasonality and prevalence of RV genotypes were estimated. Incidence rates of 40

nosocomial acute GE and RVGE are expressed in terms of 1,000 subject-years with 41

95% Exact Poisson CI. Median duration of hospitalization and prolongation of 42

hospitalization due to nosocomial RVGE were reported.

43

Results: RVGE proportions were 10.7% (95%CI: 5.5–18.3) and 23.8% (95%CI: 44

20.0–28.0) of acute GE ER visits and hospitalizations, respectively; and 21.6% 45

(95%CI: 9.8–38.2) of nosocomial acute GE cases. The majority of RVGE cases 46

occurred in children aged <24months (53.0%). RV infection peaked between 47

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December and May (31.4%). The most common RV genotypes were G4 (59.6%) and 48

P[8] (75.2%). Median duration of RVGE hospitalization was 4 days (range: 1–49

10days). Incidence of nosocomial RVGE was 0.3 (95%CI: 0.2–0.7) per 1,000 50

children-years. Median prolongation of hospitalization due to nosocomial RVGE was 51

5 days (range: 4–7days). 52

Conclusions: Our analysis report low proportions of RVGE among acute GE cases in 53

Greece which may be attributable to available RV vaccination in Greece. Future 54

impact/effectiveness studies are necessary to confirm this finding. 55

Clinical Trial Registration: NCT00751686 56

Word Count: 300/300 57

58

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ARTICLE SUMMARY 59

Article focus 60

o This prospective, hospital-based observational study aimed to provide data on 61

the epidemiology of RVGE disease one year after RV vaccines became 62

available in Greece. 63

Key Messages 64

o The present study reports lower proportions of RVGE disease in Greece than 65

reported prior to RV vaccine introduction. 66

Strengths and Limitations 67

o The prospective design allowed us to collect robust demographical and clinical 68

data on children with RVGE disease as well as to confirm RVGE cases by 69

stool testing. 70

o Limitations include the low numbers of subjects that were enrolled which 71

resulted in RVGE proportions that may not be fully representative of the 72

pediatric population in Greece: Additionally, we did not have data for the 73

same settings prior to vaccine introduction to assess any decline in the burden 74

of RVGE disease after implementation of RV vaccines in Greece. 75

76

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INTRODUCTION 77

Rotavirus (RV) is the most common cause of acute gastroenteritis (GE) in children 78

aged <5 years worldwide[1, 2]. In the European Union (EU), RVGE is the most 79

frequent vaccine-preventable illness in children aged <5 years and is associated with 80

significant morbidity[3−5]. Few observational studies describe the epidemiology of 81

RVGE in Greece[6−10]. RVGE proportions depending on the season have been 82

reported in the range of 20.0−50.0% of acute GE cases[6−10]. Two live, oral RV 83

vaccines– Rotarix™ (GlaxoSmithKline Vaccines, Belgium) and RotaTeq®

(Merck and 84

Co., Inc., Whitehouse Station, NJ, USA) have been introduced worldwide and widely 85

used since 2006[11]. Many countries in the EU have implemented vaccination of 86

healthy infants against RV following the recommendation of the World Health 87

Organization[11, 12]. 88

Although, RV vaccination in Greece was included in the national immunization 89

programme in December 2011[13], the vaccine coverage attained to-date is low, 90

which is due in part attributed to the cost of the vaccine with partial re-imbursement 91

(75%)[12]. Moreover, rotavirus vaccination in Greece is an optional vaccine and is 92

recommended only for high-risk groups[13], which has led to the perception that 93

RVGE is not a serious disease[12]. Some recent observational studies demonstrate a 94

decline in the burden of RVGE disease in Greece[9, 10] since vaccine introduction in 95

2007; however, further investigation is warranted to assess whether this decline was 96

due to vaccine uptake or not. This prospective, hospital-based observational study 97

aimed to provide data on the epidemiology of RVGE disease one year after RV 98

vaccines became available in Greece.99

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METHODS 100

� Study design and subjects 101

This prospective, hospital-based, multi-center, study was conducted at six hospitals in 102

Greece between July 2008 and March 2010. The study hospitals were selected based 103

on an established pediatric clinic network which included metropolitan general 104

hospitals with tertiary pediatric clinics which were used as reference sites for pediatric 105

diseases including GE. The hospitals covered approximately 70% of the pediatric 106

population in Greece. Surveillance was conducted for a time period of 12 months at 107

each hospital. 108

The study included a main study visit and a follow-up visit or phone call 14 days after 109

the main study visit. Children aged <5 years who visited the emergency room (ER) or 110

hospitalized with acute GE (defined as the occurrence of diarrhea for <14 days) or 111

developed acute GE at least 48 hours after hospitalization; and with a RV-positive 112

stool sample were enrolled in the study. Children with acute GE always visited the ER 113

first and were discharged if the case of acute GE was diagnosed as mild. The acute GE 114

cases were hospitalized if the acute GE episode was considered to be severe. 115

Additionally, subjects who developed acute GE at least 48 hours after hospitalization 116

for any other cause were also included for stool testing. If the stool samples were not 117

tested at the time of the visit, then the parent/guardian was requested to provide a 118

sample within four days of the study visit. A child became ineligible to participate in 119

the study on the day of his/her fifth birthday. If a child who was previously enrolled 120

visited any of the study centers included in this study with a new episode of GE and 121

with a minimum of 14 symptom-free days since the previous episode, then the child 122

was enrolled in the study as a new case of acute GE. Subject who developed acute GE 123

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at least 48 hours after hospitalization (for any other cause) was listed as a case of 124

nosocomial infection. 125

Parents of enrolled children were interviewed to obtain demographic information such 126

as date of birth and gender, medical history, information about the general symptoms 127

of the GE episode (fever, diarrhea, vomiting, weight loss and behavioral symptoms) 128

and treatment of the current acute GE episode. If the child was hospitalized, the date of 129

discharge and follow-up information after discharge were recorded. A follow-up 130

phone call to the parent/guardian of the enrolled child or where feasible, an additional 131

visit 14 days after the most recent episode of RVGE to ascertain the clinical outcome 132

of the episode marked completion of procedures for the case. 133

� Estimation of sample size 134

Population for target enrolment considered was all children <5 years of age seen at the 135

selected hospital ER departments and hospitalizations for acute GE or with 136

nosocomial RV infection; and with a RV-positive test during the surveillance period. 137

Across all the study sites selected in Greece, the target enrolment was based on the 138

assumption that 30.0% (95% CI: 23.6, 36.4) of acute GE cases were due to RV and the 139

incidence of nosocomial RVGE was 2.5 per 1,000 child-days (95% CI: 1.4, 4.4) of 140

hospitalization[1, 7]. 141

� Ethical approvals 142

Written informed consent was obtained from the parents/guardians prior to the 143

conduct of any study procedures and before enrolment of the children into the study. 144

The study protocol and the informed consent were reviewed and approved by the 145

Institutional Review Boards and the Greek National Drug Organization. The study was 146

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conducted according to the principles of Good Clinical Practice, the Declaration of 147

Helsinki, 1996 and local regulations of the country. 148

� Laboratory assays 149

Stool samples were screened for the presence of RV antigen using an 150

immunochromatographic qualitative test kit, RotaStrip™ (C-1001; Coris BioConcept, 151

Gembloux, Belgium)[14]. RV-positive stool samples were genotyped at the 152

Laboratory of Diagnostic Cytology, University Hospital, ATTIKON, Athens, Greece 153

using a two-step reverse transcriptase-polymerase chain reaction (RT-PCR). 154

Multiplexed PCR was performed using a real-time PCR machine with type specific 155

primers and TaqMan®

probes[15]. 156

� Endpoints and statistical analysis 157

Categorical data (gender, seasonal distribution and disease severity) are presented as 158

proportions with one decimal. Occurrence of RVGE among all acute GE ER visits and 159

hospitalizations and occurrence of nosocomial RVGE are reported with 95% exact 160

confidence interval (CI). Incidence rates of nosocomial acute GE and RVGE are 161

expressed in terms of 1,000 subject-years with 95% Exact Poisson CI[16]. Incidence 162

rate was calculated by dividing the number of nosocomial RVGE cases by the number 163

of hospitalized children (for any cause) which was identified as the group at a risk of 164

acquiring RV infection. The severity of GE episodes was scored on the basis of 20-165

point Vesikari scale[17]. A score of ≥11 on the Vesikari scale indicated severe GE. All 166

statistical analyses were performed using Statistical Analysis System (SAS®

) version 167

9.2.

168

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Target journal: BMJ OPEN CONFIDENTIAL 8-Jul-13

9

RESULTS 169

� Study population 170

During the study period, 29,504 ER visits and 22,963 hospitalizations for any cause 171

were reported in children aged <5 years at the study hospitals. Of these, 7.9% (2,333; 172

95% CI: 7.6, 8.2) and 5.7% (1,311; 95% CI: 5.4, 6.0) of the children visited the ER 173

and were hospitalized for acute GE, respectively. Stool samples were collected from 174

4.4% (103/2,333) of children who visited the ER for acute GE, 34.9% (458/1,311) of 175

children hospitalized with acute GE and 72.5% (37/51) of children diagnosed as 176

nosocomial acute GE. 177

� Occurrence of RVGE 178

The proportions of RVGE cases were 10.7% (11/103; 95% CI: 5.5, 18.3) of acute GE 179

ER visits, 23.8% (109/458; 95% CI: 20.0, 28.0) of acute GE hospitalizations and 180

21.6% (8/37; 95% CI: 9.8, 38.2) of nosocomial acute GE cases. Therefore, a total of 181

128 RVGE cases were enrolled in the study (Figure 1). The median age of the children 182

enrolled in the study was 19.5 months (range: 0.0–58.0 months); 53.9% children were 183

male. The demographic characteristics of children with confirmed RVGE are 184

summarized in Table 1. Among the RVGE cases, 53.0% of the cases were observed in 185

children <24 months of age. The highest number of RVGE cases was reported in 186

infants aged 6−12 months (22/128; 17.2%), followed by infants aged <6 months 187

(17/128; 13.3%) and children aged 12−18 months (17/128; 13.3%). The age 188

distributions of RVGE cases by subject groups i.e. ER visits, hospitalizations and 189

nosocomial RVGE are shown in Figure 2.190

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10

Table 1 Study population and RVGE disease characteristics 191 Parameters/ Subject group Hospitalizations (N=109) ER visits (N=11) Nosocomial (N=8) RV+ (N=128)

Age (months) Median

Range

21.0

0.0−58.0

21.0

3.0−58.0

9.0

1.0−44.0

19.5

0−58

Gender (%)

Male

Female

49.5

50.5

72.7

27.3

87.5

12.5

53.9

46.1

Hospitalization duration (days)

median (range)

Overall

Age groups

<6 months

6−12 months

12-24 months

24−<60 months

4.0 (1.0−10.0)

5.0 (3.0−10.0)

5.0 (3.0−10.0) 4.5 (3.0−8.0)

4.0 (1.0−8.0)

-

5.0 (4.0−7.0)

5.0 (5.0−5.0)

5.0 (5.0−7.0) 5.5 (5.0−6.0)

5.5 (4.0−7.0)

4.0 (1.0−10.0)

5.0 (3.0−10.0)

5.0 (3.0−10.0) 5.0 (3.0−8.0)

4.0 (1.0−8.0)

n (%)

Time point Before During Before During Before During Before During

Severity

Mild (<7)

Moderate (7−10) Severe (≥11)

17 (15.6)

28 (25.7) 64 (58.7)

18 (16.5)

43 (39.4) 48 (44.0)

3 (27.3)

5 (45.5) 3 (27.3)

8 (72.7)

2 (18.2) 1 (9.1)

8 (100.0)

- -

1 (12.5)

3 (37.5) 4 (50.0)

28 (21.9)

33 (25.8) 67 (52.3)

27 (21.1)

48 (37.5) 53 (41.4)

Symptoms Vomiting

Fever

Diarrhea

78 (71.6)

66 (60.6)

90 (82.6)

62 (56.9)

71 (65.1)

102 (93.6)

8 (72.7)

8 (72.7)

11 (100.0)

3 (30.0)

5 (50.0)

7 (70.0)

-

6 (75.0)

2 (25.0)

8 (100.0)

86 (71.7)

74 (61.7)

101 (84.2)

71 (55.9)

78 (61.4)

117 (92.1)

Treatment received

Oral rehydration

IV rehydration

37 (33.9)

4 (3.7)

64 (58.7)

99 (90.8)

2 (18.2)

-

2 (20.0)

1 (10.0)

- 5 (62.5)

7 (87.5)

39 (32.5)

4 (3.3)

71 (55.9)

107 (84.3)

Outcome at discharge

Recovered 109 (100.0) 11 (100.0) 8 (100.0) 128 (100.0)

Follow-up 14 days after discharge

Diarrhea 8 (8.2) 3 (27.3) 0 (0) 11 (9.6)

RV Genotype distribution

G1 (% of total RV+)

G2

G3

G4

P4

P8

16 (17.4)

6 (6.5)

4 (4.3)

56 (60.9)

6 (6.5)

71 (77.2)

3 (33.3)

-

-

5 (55.6)

-

7 (77.8)

1 (12.5)

1 (12.5)

-

4 (50.0)

1 (12.5)

4 (50.0)

20 (18.3)

7 (6.4)

4 (3.7)

65 (59.6)

7 (6.4)

82 (75.2)

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11

� Nosocomial RVGE 192

The demographic characteristics of children confirmed with nosocomial RVGE are 193

summarized in Table 1. The median age of children with nosocomial RVGE was 9.0 194

months (range: 1.0−44.0 months). RVGE proportion among nosocomial acute GE was 195

21.6% (8/37; 95% CI: 9.8, 38.2). Median additional hospitalization duration due to 196

nosocomial RV infection was 5 days (range: 4−7 days).The incidence rates of 197

nosocomial acute GE and nosocomial RVGE in children aged <5 years were 2.2 per 198

1,000 children-years (95% CI: 1.7, 2.9) and 0.3 per 1,000 children-years (95% CI: 0.2, 199

0.7), respectively. 200

� RVGE disease characteristics 201

Higher numbers of RVGE cases (Figure 3) were reported between December and May 202

with an overall RVGE proportion of 31.4% (114/363) among those tested, when 203

compared to the rest of the year. During December and May, the proportion of RVGE 204

among acute GE hospitalizations was 34.3% (95/277) among those tested. The highest 205

number of RVGE cases was reported in April 2009 (41.3%; n=26). The highest 206

number of RVGE cases in hospitalized acute GE cases was recorded in January 2009 207

(17.4%; 19/109) whereas among acute GE ER visits the highest number of RVGE 208

cases was recorded in April 2009 (45.5%; 5/11). The distributions of acute GE and 209

RVGE cases each month of the year are shown in Figure 3. 210

Among the RVGE cases, 85.2% (109/128) of the samples were genotyped. Of these, 211

81.8% (9/11), 84.4% (92/109) and all (100.0%; 8/8) samples from the different subject 212

groups i.e. ER visits, hospitalizations and nosocomial RVGE were genotyped. The 213

most commonly detected RV genotypes were G4 (59.6%; 65/109) and P[8] (75.2%; 214

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12

82/109). The RV genotype distributions by subject groups are summarized in Table 1. 215

Data on severity, symptoms, treatment and outcome of the acute GE episode; RVGE 216

hospitalization duration and follow-up are shown in Table 1. Before and during the 217

visit respectively, 52.3% (67/128) and 41.4% (53/128) of RVGE cases were reported 218

as severe. Before and during the visit, diarrhea was reported in 84.2% (101/128) and 219

92.1% (117/128) of RVGE cases, respectively. Fever and vomiting were reported in 220

61.7% (74/128) and 71.7% (86/128) of RVGE cases before the visit, respectively. 221

During the visit, 61.4% (78/128) and 55.9% (71/128) of RVGE cases reported fever 222

and vomiting, respectively. After 14 days of patient discharge from the hospital, 223

telephone follow-up revealed that 9.6% (11/128) of RVGE cases still reported 224

episodes of diarrhea. The median duration of RVGE hospitalization was 4 days (range: 225

1−10 days), with the longest durations in children aged <1 year (Table 1). Regarding 226

treatment of GE, oral rehydration therapy (55.9%; 71/128) was the preferred mode of 227

treatment administered prior to the hospital visit. During the hospital visit, the 228

preferred mode of treatment administered was IV rehydration therapy which was given 229

to 84.3% (107/128) of RVGE cases (Table 1). 230

Overall, 3.9% (5/128) and 0.8% (1/128) of RVGE cases had a history of pulmonary or 231

cardiac disease, respectively. Additionally, 7.0% (9/128) of RVGE cases had a 232

previous history of acute GE. All enrolled children had recovered at the time of 233

discharge from the hospital. 234

235

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DISCUSSION 236

Findings from the present study add to the existing epidemiological data on RVGE 237

disease following the introduction of RV vaccination in Greece in 2007. Our data 238

indicate that 10.7% of acute GE ER visits and 23.8% of acute GE hospitalizations 239

were caused by RV. Since introduction of RV vaccines in Greece in 2007, lower 240

proportions of acute GE due to RV have been recorded[9, 10]. In Greece, during 241

2008−09, RV was responsible for 24.7% of acute GE hospitalizations[9]. Trimis et al 242

reported a slight reduction in annual RVGE rates between 2006 and 2010[10]; 243

although the proportions during the RV season were consistent with previous 244

studies[7, 8]. Trimis et al also reported that the likelihood of RV infection among 245

children hospitalized for acute GE between 2008 and 2010 in Greece was 246

significantly reduced when compared to children hospitalized for acute GE between 247

2006 and 2008 (odds ration [OR] = 0.64; 95% CI: 0.49, 0.84, p<0.001)[10]. The 248

present study reports lower proportions of RVGE disease in Greece than reported 249

prior to RV vaccine introduction; however, comparable proportions of RVGE were 250

estimated to those reported after vaccine introduction in Greece. We assume that these 251

findings may be the result of protection conferred directly by vaccination in young 252

children although our study did not have data on RVGE burden prior to vaccination 253

introduction. Prospective monitoring is warranted to confirm any decline in the 254

RVGE disease burden due to vaccine uptake in Greece. 255

In our study the peak in RV infection was reported between December and May and 256

RV was responsible for 31.4% and 34.3% of all acute GE and hospitalized acute GE, 257

respectively. In Greece, during the RV season in 2006, RV was responsible for 49.1% 258

and 45.7% of acute GE ER visits and hospitalizations, respectively[7]. Similar 259

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proportions were reported between January 2007 and June 2008 in Greece where RV 260

was responsible for 42.3% and 47.8% of acute GE ER visits and hospitalizations in 261

children <5 years of age with the number of RVGE cases peaking between January 262

and April[7, 8]. Published data from Greece suggests late winter seasonality for 263

RVGE disease (January to April)[6−9]. However, in countries in the EU where RV 264

vaccination has been implemented through the national programmes the RV seasonal 265

peaks were delayed and attenuated post-vaccination[18−20] when compared to the 266

RV seasonal peaks observed in Greece. Our analysis revealed that the majority of 267

RVGE cases were reported in young children aged<24 months, which has also been 268

observed in European countries previously[21]. Notably, the peak of RV infection 269

coincides with the peak of other severe infectious diseases in young children thereby 270

adding to the already existing pressure on health care services. Our data reports G4 271

and G1 were the most common G types whereas P8 and P4 were the most common P 272

types that were detected in the majority of stool samples collected in this analysis. 273

These reports are in-line with published genotype data in Greece[8, 10] and from 274

European countries[22]. The median duration of hospitalization for RVGE cases was 275

4 days; this was within the range reported for countries in Western Europe (2.5−5.0 276

days)[22]. This median duration of hospitalization was however significantly lower 277

than the mean duration of RVGE hospitalization (5.14 ± 3.18 days) reported for 278

Greece previously[7]. 279

The incidence rate of nosocomial RVGE in children aged <5 years was 0.3 per 1,000 280

children-years and median additional hospitalization duration due to nosocomial RV 281

infection was 5 days. The burden of nosocomial RVGE in the present study was lower 282

than that reported for countries in Europe and with a lower median additional 283

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15

hospitalization duration (5 days [range: 4−7 days]) than that reported for Europe 284

(range: 6.3−15.0 days)[23]. Data from our study indicates that the proportions of 285

severe acute GE episodes among RVGE cases were high; severe episodes of acute GE 286

are associated with long durations of hospitalization. Additionally, the proportions of 287

children reporting vomiting and fever along with severe episodes of diarrhea were 288

high. Consequently, all these factors result in an additional consumption of medical 289

resources which may increase the economic burden associated with RVGE in Greece. 290

In-line with the recommendation from the World Health Organization, vaccination 291

against RV is now recommended in European guidelines[24]. Several countries in the 292

EU (Belgium[18], Germany[19], France[25], Austria[20], and Spain[26]) have 293

reported a positive impact following introduction RV vaccination in their national 294

immunization programmes. Although RV vaccination in Greece is available through 295

the national immunization programme[13] it is still an optional vaccine and is 296

recommended only for the high-risk groups. We expect that awareness about RVGE 297

disease in addition to widespread implementation of RV vaccines may help further 298

reduce the burden of RVGE disease in Greece. 299

The present analysis has several strengths and limitations. The prospective design 300

allowed us to collect robust demographical and clinical data on children with RVGE 301

disease as well as to confirm RVGE cases by stool testing. The main limitation of our 302

study was that low numbers were enrolled which resulted in RVGE proportions that 303

may not be fully representative of the pediatric population in Greece: Indeed 4.4% of 304

acute GE ER visits and 34.9% of acute GE hospitalizations were tested for RV in the 305

present study. This proportion was relatively higher for nosocomial acute GE cases 306

(72.5%). Additionally, we did not have data for the same settings prior to vaccine 307

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16

introduction to assess any decline in the burden of RVGE disease after 308

implementation of RV vaccines in Greece. Given these limitations, we did however 309

perform an exhaustive review of published literature on RVGE epidemiology in 310

Greece which allowed for comparison by hospital sites, common testing methodology 311

and time period. 312

In conclusion, data from the present study provides evidence of low proportions of 313

RVGE among acute GE which may be attributable to available RV vaccination in 314

Greece. However, appropriate impact/effectiveness studies are necessary to confirm 315

this finding. 316

317

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ACKNOWLEDGEMENTS 318

The authors are grateful to Roeland Van Kerckhoven (Keyrus Biopharma) for 319

editorial assistance and publication coordination on behalf of GlaxoSmithKline group 320

of companies and to Amrita Ostawal (consultant publications writer to 321

GlaxoSmithKline group of companies) for medical writing. 322

FUNDING SOURCE 323

GlaxoSmithKline (GSK) Biologicals SA was the funding source and was involved in 324

all stages of the study conduct and analysis. GSK Biologicals SA also funded all costs 325

associated with the development and the publishing of the present manuscript. All 326

authors had full access to the data and agreed with the submission of the publication. 327

COMPETING INTERESTS 328

Andreas Konstantopoulos received employment (private practice) fees outside of this 329

present publication. Athanasios Tragiannidis received a grant from GlaxoSmithKline 330

group of companies for the study, whereas Vana Papaevangelou’s institution received 331

a grant for the present study. Outside the present publication, Vana Papaevangelou 332

has also received fees for VHPB and WAVE board membership, talks at national and 333

international meetings, lectures on varicella vaccine and travel/accommodation/ 334

meeting expenses for ESPID conference. Ioannis Kavaliotis has received honoraria 335

from GSK for scientific presentations on vaccines at national congresses and 336

travel/accommodation/meeting expenses for national and international congresses. 337

Adriani Spanaki and Sotirios Fouzas declared no conflict of interest. Kusuma Gopala 338

and Katsiaryna Holl are employees of GlaxoSmithKline group of companies. The 339

other authors declared no conflict of interest. 340

AUTHORS’ CONTRIBUTIONS 341

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AK, AT, SF, GK, OT, EM, AS, SM, DK, VP, KG and KH took part in either the 342

conception and design of the study, protocol development, study results analysis and 343

interpretation and/or collection of the data. KG performed the statistical data analyses. 344

All authors reviewed and commented on the draft manuscript, and all authors read and 345

approved the final manuscript. 346

LIST OF ABBREVIATIONS 347

CI: confidence interval; ER: emergency room; GE: gastroenteritis; GSK: 348

GlaxoSmithKline; IV: intravenous; OR: odds ratio; RV: rotavirus RT-PCR: reverse 349

transcriptase-polymerase chain reaction 350

TRADEMARK 351

RotaStrip is a trademark of Coris BioConcept, Gembloux, Belgium. Rotarix is a 352

registered trademark of GlaxoSmithKline group of companies. RotaTeq is a registered 353

trademark of Merck and Co., Inc., USA. 354

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19

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A%CE%A9%CE%9D.pdf; Access date: 16-Jan-2013

14. Coris BioConcept. RotaStrip™. Rapid diagnostic test for in vitro detection of

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2013

15. Kottaridi C, Spathis AT, Ntova CK, et al. Evaluation of a multiplex real time

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19. Koch J, Wiese-Posselt M. Epidemiology of Rotavirus Infections in Children less

than 5 years of age, Germany 2001−2008. Pediatr Infect Dis J 2011;30:112−17.

20. Paulke-Korinek M, Kundi M, Rendi-Wagner P, et al. Herd immunity after two

years of the universal mass vaccination program against rotavirus gastroenteritis

in Austria. Vaccine 2011;29:2791–96.

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21. Giaquinto C, van Damme P; the REVEAL study group. Age distribution of

pediatric rotavirus gastroenteritis cases in Europe: the REVEAL study. Scand J

Infect Dis 2010;42:142–47.

22. Ogilvie I, Khoury H, Goetghebeur MM, et al. Burden of community-acquired

and nosocomial rotavirus gastroenteritis in the pediatric population of Western

Europe: a scoping review. BMC Infect Dis 2012;12:62.

23. Gleizes O, Desselberger U, Tatochenko V, et al. Nosocomial rotavirus infection

in European countries: a review of the epidemiology, severity and economic

burden of hospital-acquired rotavirus disease. Pediatr Infect Dis J

2006;25:S12−21.

24. Vesikari T, Van Damme P, Giaquinto C, et al. European Society for Paediatric

Infectious Diseases/European Society for Paediatric Gastroenterology,

Hepatology, and Nutrition evidence-based recommendations for rotavirus

vaccination in Europe: executive summary. J Pediatr Gastroenterol Nutr

2008;46:615−18.

25. Gagneur A, Nowak E, Lemaitre T, et al. Impact of rotavirus vaccination on

hospitalizations for rotavirus diarrhea: The IVANHOE study. Vaccine 2011;29:

3753−59.

26. Martinon-Torres F, Alejandro MB, Collazo LR, et al. Effectiveness of rotavirus

vaccination in Spain. Hum Vaccin 2011;7:757–61.

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FIGURE LEGENDS

Figure 1 Study design

Figure 2 Age distribution of children aged <5 years

Figure 3 Seasonal distribution of Acute GE and RVGE cases in children aged <5

year

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254x190mm (96 x 96 DPI)

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161x145mm (96 x 96 DPI)

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151x125mm (96 x 96 DPI)

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109355 CONFIDENTIAL 16-Jan-13

1

STROBE Statement—Checklist of items that should be included in reports of cross-sectional studies

Item No Recommendation Comments

Title and

abstract

1 (a) Indicate the study’s design with a

commonly used term in the title or the abstract

(a) Included

(b) Provide in the abstract an informative and

balanced summary of what was done and what

was found

(b) Included

Introduction

Background/ratio

nale

2 Explain the scientific background and rationale

for the investigation being reported

Yes

Objectives 3 State specific objectives, including any pre-

specified hypotheses

Yes

Methods

Study design 4 Present key elements of study design early in

the paper

Yes

Setting 5 Describe the setting, locations, and relevant

dates, including periods of recruitment,

exposure, follow-up, and data collection

Yes

Participants 6 (a) Give the eligibility criteria, and the sources

and methods of selection of participants

Yes

Variables 7 Clearly define all outcomes, exposures,

predictors, potential confounders, and effect

modifiers. Give diagnostic criteria, if applicable

Yes

Data sources/

measurement

8* For each variable of interest, give sources of

data and details of methods of assessment

(measurement). Describe comparability of

assessment methods if there is more than one

group

Yes

Bias 9 Describe any efforts to address potential

sources of bias

The sources of bias or

representativeness of results have

been discussed as limitations

Study size 10 Explain how the study size was arrived at Yes

Quantitative

variables

11 Explain how quantitative variables were

handled in the analyses. If applicable, describe

which groupings were chosen and why

Yes

Statistical

methods

12 (a) Describe all statistical methods, including

those used to control for confounding

Yes

(b) Describe any methods used to examine

subgroups and interactions

Yes

(c) Explain how missing data were addressed Yes

(d) If applicable, describe analytical methods

taking account of sampling strategy

Yes

(e) Describe any sensitivity analyses NA

Results

Participants 13* (a) Report numbers of individuals at each stage

of study—eg numbers potentially eligible,

Yes

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2

examined for eligibility, confirmed eligible,

included in the study, completing follow-up,

and analysed

(b) Give reasons for non-participation at each

stage

Yes

(c) Consider use of a flow diagram Flow diagram included

Descriptive data 14* (a) Give characteristics of study participants (eg

demographic, clinical, social) and information

on exposures and potential confounders

Yes

(b) Indicate number of participants with

missing data for each variable of interest

NA

Outcome data 15* Report numbers of outcome events or summary

measures

Yes

Main results 16 (a) Give unadjusted estimates and, if

applicable, confounder-adjusted estimates and

their precision (eg, 95% confidence interval).

Make clear which confounders were adjusted

for and why they were included

Yes

(b) Report category boundaries when

continuous variables were categorized

Yes

(c) If relevant, consider translating estimates of

relative risk into absolute risk for a meaningful

time period

NA

Other analyses 17 Report other analyses done—eg analyses of

subgroups and interactions, and sensitivity

analyses

Yes

Discussion

Key results 18 Summarise key results with reference to study

objectives

Yes

Limitations 19 Discuss limitations of the study, taking into

account sources of potential bias or

imprecision. Discuss both direction and

magnitude of any potential bias

Yes

Interpretation 20 Give a cautious overall interpretation of results

considering objectives, limitations, multiplicity

of analyses, results from similar studies, and

other relevant evidence

Yes

Generalizability 21 Discuss the generalizability (external validity)

of the study results

Yes

Other information

Funding 22 Give the source of funding and the role of the

funders for the present study and, if applicable,

for the original study on which the present

article is based

Yes

*Give information separately for exposed and unexposed groups.

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3

Note: An Explanation and Elaboration article discusses each checklist item and gives methodological background and

published examples of transparent reporting. The STROBE checklist is best used in conjunction with this article (freely

available on the Web sites of PLoS Medicine at http://www.plosmedicine.org/, Annals of Internal Medicine at

http://www.annals.org/, and Epidemiology at http://www.epidem.com/). Information on the STROBE Initiative is

available at www.strobe-statement.org.

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Burden of rotavirus gastroenteritis in children <5 years of age in Greece: Hospital-based prospective surveillance

(2008−2010)

Journal: BMJ Open

Manuscript ID: bmjopen-2013-003570.R1

Article Type: Research

Date Submitted by the Author: 22-Oct-2013

Complete List of Authors: Konstantopoulos, Andreas Tragiannidis, Athanasios Fouzas, Sotirios

Kavaliotis, John Tsiatsou, Olga Michailidou, Elisa Spanaki, Ariana Mantagos, Stefanos Kafetzis, Dimitrios Papaevangelou, Vana Gopala, Kusuma Holl, Katsiaryna

<b>Primary Subject Heading</b>:

Infectious diseases

Secondary Subject Heading: Infectious diseases, Epidemiology

Keywords: INFECTIOUS DISEASES, Epidemiology < INFECTIOUS DISEASES, Public health < INFECTIOUS DISEASES


BMJ Open on A

pril 28, 2020 by guest. Protected by copyright.

http://bmjopen.bm

j.com/

BM

J Open: first published as 10.1136/bm

jopen-2013-003570 on 11 Decem

ber 2013. Dow

nloaded from



Target journal: BMJ OPEN CONFIDENTIAL 12 November 2013

TITLE PAGE 1





2 Fouzas Sotirios,

3 5



4 Spanaki Ariana,

5 Mantagos 6



6 Gopala Kusuma,

7 Holl 7

Katsiaryna8 8




Tel: +30 210 6383052 12

Fax: +30 210 6383054 13















Belgium 23


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Word count: 2795/4000 25

ABSTRACT 26






in Greece. 32












43





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58

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ARTICLE SUMMARY 59

Article focus 60




Key Messages 64






stool testing. 70






76

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INTRODUCTION 77








(Merck and 84
















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METHODS 100








each hospital. 108
















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probes[15]. 156












) version 167

9.2.

168

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Target journal: BMJ OPEN CONFIDENTIAL 12-Nov-13

9

RESULTS 169






















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10


Age (months) Median

Range

21.0

0.0−58.0

21.0

3.0−58.0

9.0

1.0−44.0

19.5

0−58

Gender (%)

Male

Female

49.5

50.5

72.7

27.3

87.5

12.5

53.9

46.1


median (range)

Overall

Age groups

<6 months

6−12 months

12-24 months

24−<60 months

4.0 (1.0−10.0)

5.0 (3.0−10.0)

5.0 (3.0−10.0) 4.5 (3.0−8.0)

4.0 (1.0−8.0)

-

5.0 (4.0−7.0)

5.0 (5.0−5.0)

5.0 (5.0−7.0) 5.5 (5.0−6.0)

5.5 (4.0−7.0)

4.0 (1.0−10.0)

5.0 (3.0−10.0)

5.0 (3.0−10.0) 5.0 (3.0−8.0)

4.0 (1.0−8.0)

n (%)


Severity

Mild (<7)


17 (15.6)

28 (25.7) 64 (58.7)

18 (16.5)

43 (39.4) 48 (44.0)

3 (27.3)

5 (45.5) 3 (27.3)

8 (72.7)

2 (18.2) 1 (9.1)

8 (100.0)

- -

1 (12.5)

3 (37.5) 4 (50.0)

28 (21.9)

33 (25.8) 67 (52.3)

27 (21.1)

48 (37.5) 53 (41.4)

Symptoms Vomiting

Fever

Diarrhea

78 (71.6)

66 (60.6)

90 (82.6)

62 (56.9)

71 (65.1)

102 (93.6)

8 (72.7)

8 (72.7)

11 (100.0)

3 (30.0)

5 (50.0)

7 (70.0)

-

6 (75.0)

2 (25.0)

8 (100.0)

86 (71.7)

74 (61.7)

101 (84.2)

71 (55.9)

78 (61.4)

117 (92.1)

Treatment received

Oral rehydration

IV rehydration

37 (33.9)

4 (3.7)

64 (58.7)

99 (90.8)

2 (18.2)

-

2 (20.0)

1 (10.0)

- 5 (62.5)

7 (87.5)

39 (32.5)

4 (3.3)

71 (55.9)

107 (84.3)


Recovered 109 (100.0) 11 (100.0) 8 (100.0) 128 (100.0)


Diarrhea 8 (8.2) 3 (27.3) 0 (0) 11 (9.6)


G1 (% of total RV+)

G2

G3

G4

P4

P8

16 (17.4)

6 (6.5)

4 (4.3)

56 (60.9)

6 (6.5)

71 (77.2)

3 (33.3)

-

-

5 (55.6)

-

7 (77.8)

1 (12.5)

1 (12.5)

-

4 (50.0)

1 (12.5)

4 (50.0)

20 (18.3)

7 (6.4)

4 (3.7)

65 (59.6)

7 (6.4)

82 (75.2)

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11
























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235

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13

DISCUSSION 236
























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14

























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15

























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16









this finding. 316

317

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17






FUNDING SOURCE 323



















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18










TRADEMARK 351




DATA SHARING 355

Researchers can request access to anonymised patient level data from GSK clinical 356

studies to conduct further research through the GSK website at the following URL 357

address: https://clinicalstudydata.gsk.com.358

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19

REFERENCES














2009;15:596−98.




2008;167:707–08.



Virol 2011;83:165–69.

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20



2012;64;333−39.












%CE%AD%CE%B1%20-


F%8E%CF%83%CE%B5%CE%B9%CF%82%20-







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21






2013








1990;22:259–267.



Infect Dis J 2011;30:e120−25.






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22



Infect Dis 2010;42:142–47.







2006;25:S12−21.





2008;46:615−18.



3753−59.



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23

FIGURE LEGENDS




year

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TITLE PAGE 1





2 Fouzas Sotirios,

3 5



4 Spanaki Ariana,

5 Mantagos 6



6 Gopala Kusuma,

7 Holl 7

Katsiaryna8 8




Tel: +30 210 6383052 12

Fax: +30 210 6383054 13















Belgium 23


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Word count: 2795/4000 25

ABSTRACT 26






in Greece. 32












43





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58

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ARTICLE SUMMARY 59

Article focus 60




Key Messages 64






stool testing. 70






76

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INTRODUCTION 77








(Merck and 84
















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METHODS 100








each hospital. 108
















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probes[15]. 156












) version 167

9.2.

168

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9

RESULTS 169






















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10


Age (months) Median

Range

21.0

0.0−58.0

21.0

3.0−58.0

9.0

1.0−44.0

19.5

0−58

Gender (%)

Male

Female

49.5

50.5

72.7

27.3

87.5

12.5

53.9

46.1


median (range)

Overall

Age groups

<6 months

6−12 months

12-24 months

24−<60 months

4.0 (1.0−10.0)

5.0 (3.0−10.0)

5.0 (3.0−10.0) 4.5 (3.0−8.0)

4.0 (1.0−8.0)

-

5.0 (4.0−7.0)

5.0 (5.0−5.0)

5.0 (5.0−7.0) 5.5 (5.0−6.0)

5.5 (4.0−7.0)

4.0 (1.0−10.0)

5.0 (3.0−10.0)

5.0 (3.0−10.0) 5.0 (3.0−8.0)

4.0 (1.0−8.0)

n (%)


Severity

Mild (<7)


17 (15.6)

28 (25.7) 64 (58.7)

18 (16.5)

43 (39.4) 48 (44.0)

3 (27.3)

5 (45.5) 3 (27.3)

8 (72.7)

2 (18.2) 1 (9.1)

8 (100.0)

- -

1 (12.5)

3 (37.5) 4 (50.0)

28 (21.9)

33 (25.8) 67 (52.3)

27 (21.1)

48 (37.5) 53 (41.4)

Symptoms Vomiting

Fever

Diarrhea

78 (71.6)

66 (60.6)

90 (82.6)

62 (56.9)

71 (65.1)

102 (93.6)

8 (72.7)

8 (72.7)

11 (100.0)

3 (30.0)

5 (50.0)

7 (70.0)

-

6 (75.0)

2 (25.0)

8 (100.0)

86 (71.7)

74 (61.7)

101 (84.2)

71 (55.9)

78 (61.4)

117 (92.1)

Treatment received

Oral rehydration

IV rehydration

37 (33.9)

4 (3.7)

64 (58.7)

99 (90.8)

2 (18.2)

-

2 (20.0)

1 (10.0)

- 5 (62.5)

7 (87.5)

39 (32.5)

4 (3.3)

71 (55.9)

107 (84.3)


Recovered 109 (100.0) 11 (100.0) 8 (100.0) 128 (100.0)


Diarrhea 8 (8.2) 3 (27.3) 0 (0) 11 (9.6)


G1 (% of total RV+)

G2

G3

G4

P4

P8

16 (17.4)

6 (6.5)

4 (4.3)

56 (60.9)

6 (6.5)

71 (77.2)

3 (33.3)

-

-

5 (55.6)

-

7 (77.8)

1 (12.5)

1 (12.5)

-

4 (50.0)

1 (12.5)

4 (50.0)

20 (18.3)

7 (6.4)

4 (3.7)

65 (59.6)

7 (6.4)

82 (75.2)

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11
























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235

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13

DISCUSSION 236
























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14

























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15

























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16









this finding. 316

317

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17






FUNDING SOURCE 323



















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TRADEMARK 351




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19

REFERENCES














2009;15:596−98.




2008;167:707–08.



Virol 2011;83:165–69.

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2012;64;333−39.












%CE%AD%CE%B1%20-


F%8E%CF%83%CE%B5%CE%B9%CF%82%20-







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21






2013








1990;22:259–267.



Infect Dis J 2011;30:e120−25.






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22



Infect Dis 2010;42:142–47.







2006;25:S12−21.





2008;46:615−18.



3753−59.



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23

FIGURE LEGENDS




year

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254x190mm (300 x 300 DPI)

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161x145mm (300 x 300 DPI)

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151x125mm (300 x 300 DPI)

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1

STROBE Statement—Checklist of items that should be included in reports of cross-sectional studies

Item No Recommendation Comments

Title and

abstract

1 (a) Indicate the study’s design with a

commonly used term in the title or the abstract

(a) Included

(b) Provide in the abstract an informative and

balanced summary of what was done and what

was found

(b) Included

Introduction

Background/ratio

nale

2 Explain the scientific background and rationale

for the investigation being reported

Yes

Objectives 3 State specific objectives, including any pre-

specified hypotheses

Yes

Methods

Study design 4 Present key elements of study design early in

the paper

Yes

Setting 5 Describe the setting, locations, and relevant

dates, including periods of recruitment,

exposure, follow-up, and data collection

Yes

Participants 6 (a) Give the eligibility criteria, and the sources

and methods of selection of participants

Yes

Variables 7 Clearly define all outcomes, exposures,

predictors, potential confounders, and effect

modifiers. Give diagnostic criteria, if applicable

Yes

Data sources/

measurement

8* For each variable of interest, give sources of

data and details of methods of assessment

(measurement). Describe comparability of

assessment methods if there is more than one

group

Yes

Bias 9 Describe any efforts to address potential

sources of bias

The sources of bias or

representativeness of results have

been discussed as limitations

Study size 10 Explain how the study size was arrived at Yes

Quantitative

variables

11 Explain how quantitative variables were

handled in the analyses. If applicable, describe

which groupings were chosen and why

Yes

Statistical

methods

12 (a) Describe all statistical methods, including

those used to control for confounding

Yes

(b) Describe any methods used to examine

subgroups and interactions

Yes

(c) Explain how missing data were addressed Yes

(d) If applicable, describe analytical methods

taking account of sampling strategy

Yes

(e) Describe any sensitivity analyses NA

Results

Participants 13* (a) Report numbers of individuals at each stage

of study—eg numbers potentially eligible,

Yes

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2

examined for eligibility, confirmed eligible,

included in the study, completing follow-up,

and analysed

(b) Give reasons for non-participation at each

stage

Yes

(c) Consider use of a flow diagram Flow diagram included

Descriptive data 14* (a) Give characteristics of study participants (eg

demographic, clinical, social) and information

on exposures and potential confounders

Yes

(b) Indicate number of participants with

missing data for each variable of interest

NA

Outcome data 15* Report numbers of outcome events or summary

measures

Yes

Main results 16 (a) Give unadjusted estimates and, if

applicable, confounder-adjusted estimates and

their precision (eg, 95% confidence interval).

Make clear which confounders were adjusted

for and why they were included

Yes

(b) Report category boundaries when

continuous variables were categorized

Yes

(c) If relevant, consider translating estimates of

relative risk into absolute risk for a meaningful

time period

NA

Other analyses 17 Report other analyses done—eg analyses of

subgroups and interactions, and sensitivity

analyses

Yes

Discussion

Key results 18 Summarise key results with reference to study

objectives

Yes

Limitations 19 Discuss limitations of the study, taking into

account sources of potential bias or

imprecision. Discuss both direction and

magnitude of any potential bias

Yes

Interpretation 20 Give a cautious overall interpretation of results

considering objectives, limitations, multiplicity

of analyses, results from similar studies, and

other relevant evidence

Yes

Generalizability 21 Discuss the generalizability (external validity)

of the study results

Yes

Other information

Funding 22 Give the source of funding and the role of the

funders for the present study and, if applicable,

for the original study on which the present

article is based

Yes

*Give information separately for exposed and unexposed groups.

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3

Note: An Explanation and Elaboration article discusses each checklist item and gives methodological background and

published examples of transparent reporting. The STROBE checklist is best used in conjunction with this article (freely

available on the Web sites of PLoS Medicine at http://www.plosmedicine.org/, Annals of Internal Medicine at

http://www.annals.org/, and Epidemiology at http://www.epidem.com/). Information on the STROBE Initiative is

available at www.strobe-statement.org.

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Documents

BMJ Open19 Street, 546 38, Thessaloniki, Greece, 5Venizeleio Hospital, Pediatric Department, 346 ... 36 Interventions: None given for the purpose of the study. ... 112 developed acute