Rotavirus Genotypes among Hospitalized Children in Egypt
• JID 2010:202 (Suppl 1) • S263
S U P P L E M E N T A R T I C L E
Rotavirus Genotypes among Hospitalized Children
in Egypt, 2000–2002
David O. Matson,1aIbrahim A. Abdel-Messih,2Carey D. Schlett,2Karin Bok,1Tiffany Wienkopff,1Thomas F. Wierzba,2
John W. Sanders,2and Robert W. Frenck, Jr2
1Center for Pediatric Research, Norfolk, Virginia;
2US Naval Medical Research Unit No. 3, Cairo, Egypt
Rotavirus type surveillance is essential to assess the success of rotavirus vaccines. Rotavirus strains collected
in 2000–2002 during hospital-based surveillance for diarrhea in Egyptian children were genotyped. Of the 259
(25.2%) rotavirus-positive specimens, 82.4% were common strains (G1p, G2p, G4p), and the emergent
G9 type was detected in 5.3% of samples.
Rotavirus is the leading cause of severe childhood di-
arrhea worldwide, resulting in ∼600,000 deaths an-
nually in children !5 years of age [1). Rotavirus infec-
tion is highly contagious and not easily controlled by
improvements in hygiene and sanitation, as evidenced
by similar incidence rates in developed and developing
nations . The only control measure likely to have a
significant impact on the incidence of severe disease is
vaccination, but circulating rotavirusesareantigenically
and genotypically diverse. The genotypic diversity of
circulating rotavirus strains needs to be assessed before,
during, and after vaccination of populations. This re-
port focuses on the diversity of rotavirus strains col-
lected during a study of pediatric gastroenteritis leading
to hospitalization in Egypt.
Potential conflicts of interest: none reported.
Financial support: none reported.
Presented in part: Meeting of the Virginia Chapter of the American Society for
Microbiology, Charlottesville, Virginia, November 2003.
Supplement sponsorship: This article is part of a supplement entitled “Rotavirus
Infection In Africa: Epidemiology, Burden of Disease, and Strain Diversity,” which
was prepared as a project of the Rotavirus Vaccine Program, a partnership among
PATH, the World Health Organization, and the US Centers for Disease Control and
Prevention, and was funded in full or in part by the GAVI Alliance.
aPresentaffiliation: Graduate PrograminPublicHealth,EasternVirginiaMedical
School and Old Dominion University, Norfolk, Virginia.
Reprints or correspondence: Dr Robert W. Frenck, Cincinnati Children’s Hospital
Medical Center, 3333 Burnet Ave, MLC 6014, Cincinnati, OH 45229
(Robert.Frenck@cchmc.org); or Dr Karen Bok, Laboratory of Infectious Diseases,
National Institute of Allergy and Infectious Diseases, National Institutes of Health,
Bldg 50, Room 6316, 50 South Dr, MSC8026, Bethesda, MD 20892
The Journal of Infectious Diseases
? 2010 by the Infectious Diseases Society of America. All rights reserved.
From May 2000 to May 2002, a hospital-based sur-
veillance study was conducted at 2 hospitals in Egypt:
Abu Homos DistrictHospital,themainreferralhospital
for a rural district in the Nile Delta, and Benha Fever
Hospital, the main referral center for a periurban area
north of Cairo . Every fifth child !5 years of age
presenting at one of these hospitals with diarrhea as
the primary complaintwaseligibleforenrollment.After
informed consent was obtained, a questionnaire de-
tailing the child’s medical history and current physical
status was completed. Two rectal swab samples and a
stool sample were collected from each child. All spec-
imens were transported within 3 days of collection to
the United States Naval Medical Research Unit No. 3
in Cairo for testing. Testing for rotaviruswasperformed
using enzyme immunoassay kits (Premier Rotaclone;
Meridian Bioscience), and positive samples were sent
to Eastern Virginia Medical School for genotyping. All
data were double-entered using Epi Info software (ver-
sion 6.01)  and analyzed using SAS software (version
Rotavirus prototype strains Wa, DS-1, ST3, K8, 69M,
Ito, OSU (provided by Fernando Fernandez, Instituto
Nacional de Tecnologia Agropecuraria, Buenos Aires,
Argentina), and F45 were cultivated in MA104 cells and
used as controls for the typing assays. Genotyping was
carried out using nested reverse transcription-poly-
merase chain reaction [4–6]. Rotavirus RNA was ex-
tracted from 10% fecal suspensions using TRIzol (Life
Technologies), following the manufacturer’s recom-
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S264 • JID 2010:202 (Suppl 1) • Matson et al
2000–2002, grouped according to the characteristics that suggest a mechanism of evolution
P and G genotypes of rotavirus isolates obtained in Abu Homos and Benha, Egypt,
Strain characteristic,agenotype No. (%) of strains
Common in surveys of countries with a temperate climate
Suggestive of reassortment in vivo
Suggestive of being introduced from animal reservoir (zoonotic transmission)
G known, P unknown
G unknown, p
G and P unknownb
aSee Iturriza-Go ´mara et al .
bPositive at first-round reverse-transcription polymerase chain reaction analysis.
cSixteen samples could not be tested because of insufficient volume.
mendations. Gene 9 was amplified using a pair of generic prim-
ers (Beg and End), and then a pool of internal primers for G1,
G2, G3, G4, G5, and G9 was used, with consensus primer 9C1.
P genotypes were determined by a similar strategy . Agarose
gel electrophoresis and ethidium bromide staining were per-
formed to visualize resulting bands.
Written informed consent was obtained from each parent at
the time of enrollment. This study was approved by the Insti-
tutional Review Board of US Naval Medical Research Unit No.
3, Cairo (Department of Defense NAMRU3.2000.0002); by the
Ministry of Health and Population, Arab Republic of Egypt;
and by the Institutional Review Board of Eastern Virginia Med-
A total of 1275 children were enrolled from the 2 hospitals. Of
the enrolled children, 1026 (80.5%) provided a stool specimen.
Enzyme immunoassay testing identified 259 (25.2%) rotavirus-
positive specimens. Genotypic combinations common world-
wide (G1p, G2p, and G4p) accounted for 82.4% of
the circulating strains in our study (Table 1). Antigenic com-
binations (G3p and G2p) suggesting reassortants of
strains common worldwide were observed in 2 samples In 13
samples (5.3%), 2 genotypic combinations were detected that
mark the G9 type that has recently been emerging worldwide.
One strain showed a reassortant of a common strain, perhaps
G1p or G4p, with the emerging G9 strains usually as-
sociated with p or p, yielding G1p. G9pstrainswere
found; these have been suggested to be of animal origin ,
but current widespread prevalence in humans allows for the
possibility of human-to-human spread.
A review of recent literature demonstratedthatG1p,G3p,
G4p, and G2p are the most common strains when typing
results are aggregated worldwide . Two additional strains,
G9p and G9p, are being reported with increasing fre-
quency . Most published typing data come from temperate
regions and, when aggregated, do not reflect patterns of G and
P type prevalence from year to year or by region. Our study
found serotype strain distributions for Egypt similar to those
aggregate data and found no significant variationfromprevious
studies in Egypt. A study conducted in Cairo from 1992 to
1993 by Radwan et al  identified rotavirus in 64 (35.6%)
of 180 neonates and infants tested. The most common G types
were G1 (17.7% specimens), G4 (17.7%) and mixed G1 and
G4 (16.1%); however, 39% of the specimens were nontypeable.
In 1995, Naficy et al  identified 46 (17%) of 272 children
in Egypt with ?1 episode of rotavirusdisease.Thepredominant
G serotypes were G1 and G2 with a combined prevalence of
89%. A novel strain, G8P, was detected for the first time
in Egypt in this cohort [11, 12]. In 1997, a review of the ep-
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Rotavirus Genotypes among Hospitalized Children in Egypt • JID 2010:202 (Suppl 1) • S265
idemiology of rotavirus diarrhea in Africa reported that sero-
type G1 was the most common (42% strains), followed by G2
(16%), G4 (12%), and G3 (4%), but G types were not deter-
mined in 26% of strains .
For countries considering a rotavirus vaccineprogram,strain
surveillance has become essential to monitor whether the dis-
tribution of circulating strains reflects the serotypes selected for
inclusion into vaccines. In 2006, 2 rotavirus vaccines were de-
ployed in many countries: RV5, containing 5 live human-bo-
vine rotavirus reassortants and displaying G1, G2, G3, G4, or
p types, and RV1, containing a live, attenuated, monovalent
G1p human rotavirus strain. The compositions of these vac-
cines differ markedly, yet both demonstrated a high degree of
efficacy in large studies across large geographic regions[14,15].
The presence of a segmented genome, at least 2 proteins/
genes known to be important for induction of protective im-
munity, the known diversity of circulating rotavirusstrains,and
the presence of animal reservoirs for human infection contrib-
ute to a concern that rotaviruses might present challenges to
mass immunization similar to those seen with influenza. On
the other hand, rotavirus strains do not move across geographic
regions as quickly as influenza viruses. This combination of
factors suggests that one or both of the newly deployed rota-
virus vaccines may exhibit high effectiveness in some regions
and not in others, and it highlights the need for continually
updated regional data, as provided here from Egypt.
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