Identification of Norovirus Infection in Adults with Acute Gastroenteritis in Jambi, Indonesia - Open Journal Systems
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Indian Journal of Public Health Research & Development, June 2020, Vol. 11, No. 6 1431
Identification of Norovirus Infection in Adults with Acute
Gastroenteritis in Jambi, Indonesia
Putri Sari Wulandari1, Rury Mega Wahyuni2, Mochamad Amin2, Laura Navika Yamani2,3, Takako
Utsumi4, Maria Inge Lusida2,5, Juniastuti1,2,5
1,5
Master Program of Tropical Medicine and Department of Microbiology, Faculty of Medicine, Universitas
Airlangga, Surabaya, Indonesia, 2Institute of Tropical Disease, Universitas Airlangga, Surabaya, Indonesia,
3Department of Epidemiology, Faculty of Public Health, Universitas Airlangga, Surabaya, Indonesia,
4Center for Infectious Diseases, Kobe University Graduate School of Medicine, Kobe, Japan, Uniastuti
Abstract
Background: Norovirus (NoV) infection is the most common cause of non-bacterial acute gastroenteritis
(AGE), which affects both adults and children. However, study of NoV in adults with AGE in Indonesia is
still limited.
Objectives: This study aimed to investigate the incidence and clinical characteristics of NoV infection, and
also genotype distribution of NoV in adults with AGE in Jambi, Indonesia.
Methods: Stool samples were collected from adults (≥18 years of age) with AGE at 3 participating hospitals
in Jambi from February to April 2019. The detection of NoV and its genotyping were carried out by Reverse
Transcriptase PCR and direct sequencing.
Results: Of the 44 stool samples collected, 4 (9.1%) were positive for NoV. Four different genotypes were
identified, namely GI.2, GII.3, GII.6, and GII.20. All adults with AGE and NoV-positive showed abdominal
pain and no dehydration, most of them experienced watery diarrhea (75%) for1432 Indian Journal of Public Health Research & Development, June 2020, Vol. 11, No. 6
gastroenteritis cases (hospitalized) among children Acute gastroenteritis was defined by the diarrhea (≥3
under-5 years and 12% of mild and moderate diarrhea loose stools or liquid stools within a 24 hours period)
cases (outpatient) among persons of all ages.(4) Clinical and lasts no longer than 14 days, possibly accompanied
infection with NoV generally has an incubation time of by vomiting, fever, and abdominal pain. The level of
12 to 48 hours, with nausea, vomiting, watery diarrhea, dehydration were classified according to WHO.(14) The
and abdominal pain.(1) characteristics (age and sex) and clinical data of the
patients were retrieved from medical records.
Norovirus, a member of the family Caliciviridae,
is a non-enveloped, positive-sense, single-strand RNA RNA extraction and reverse transcriptase
virus. Its genome contains approximately 7.7 kb in polymerase chain reaction (RT-PCR)
length, which is organized into three open reading
frames (ORFs): ORF1 encodes non-structural proteins A 10% (w/v) stool suspension of each sample in
including the RNA-dependent RNA polymerase (RdRp), distilled water was prepared, then the supernatant was
ORF2 encodes the major capsid protein VP1, and ORF3 subjected to RNA extraction using QIAamp Viral RNA
encodes the minor structural protein VP2. NoV is Mini Kit (Qiagen, Valencia, CA). The extracted RNA
classified at least into 7 genogroups, GI–GVII. GI, GII, was reverse transcribed and amplified using Superscript
and GIV genogroups have been found in humans(5,6,). III reverse transcriptase (Invitrogen, New York, NY) and
More than 30 genotypes were characterized within the random primers (Takara Bio, Kyoto, Japan). Polymerase
7 genogroups(7,8). chain reaction (PCR) amplification was subsequently
performed to detect NoV GI and GII in the capsid gene
Acute gastroenteritis is one of the most common (VP1) using the previously published primer pair of
public health problems in Indonesia and other countries. G1SKF/R and G2SKF/R, respectively.(15)
During the past several years, most studies of NoV
infection in Indonesia focused on the role of human NoV PCR products were electrophoresed on a 2% agarose
in AGE in children, while the study of NoV in adults gel containing ethidium bromide and visualized under
with AGE is still limited. In Jakarta, Indonesia, Norwalk- UV illumination.
like viruses (NLV) were detected in 9.7% from patients Sequencing and sequence analysis
>12 years of age with acute AGE.(9) Another study in
Surabaya, Indonesia reported that the prevalence of NoV Amplified cDNA fragments were sequenced by a
in asymptomatic adult population was 2.7%.(10) direct sequencing method with the BigDye terminator
cycle sequencing kit using an Applied Biosystems
Jambi is a capital and the largest city of Jambi 3500XL Genetic Analyzer (Applied Biosystems, Foster,
province, located on the east coast of cental part of CA).
Sumatra island, Indonesia. Ministry of Health of
Indonesia reported 96,397 diarrhea cases in all ages in Nucleotide sequences were aligned with the reference
Jambi(11) with the prevalence about 4.1%,(12) however the strains by the program Molecular Evolutionary Genetic
causative agents have not been reported. This study aimed Analysis (MEGA) X (http://www.megasoftware.net).
to investigate the incidence and clinical characteristic of Phylogenetic trees were constructed by the Neighbor
NoV infection, and also genotype distribution of NoV in Joining method and bootstrap resampling was performed
adults with AGE in Jambi, Indonesia. 1000 times.
Methods Results
Sample and clinical data collection Study population
Stool samples were collected from adults (≥18 A total of 44 stool samples were collected from
years of age) with AGE at 3 participating hospitals in adults with AGE at 3 participating hospitals in Jambi
Jambi, Indonesia between February to April 2019. They city. The age of patients ranged from 19 to 78 years
were collected within the first 48 hours after admission (median, 45 years). More patients were female (56.8%),
according to the World Health Organization (WHO) with the sex ratio (female/male) was 1.3.
protocol(13) and examined in Institute of Tropical
Disease, Universitas Airlangga, Surabaya, Indonesia.Indian Journal of Public Health Research & Development, June 2020, Vol. 11, No. 6 1433
Virus detection rate and clinical characteristics showed vomiting for 1 day. Abdominal pain and no
dehydration were observed in all adults with AGE and
Of the 44 stool samples collected, 4 (9.1%) were NoV-positive (Table 1).
positive for NoV. Noroviruses were identified mostly
in adults 36-64 years of age group (ranged 34-70 years, Genogroup and genotype of NoV
median 45 years, mean 48.5 years) and more frequently
in female patients (75%) of cases. Among 4 NoV-positive stool samples, most of them
was classified as GII genogroup (75%) and the rest was
Most of adults with NoV-positive had watery GI. Four different genotypes were identified, namely
diarrhea (75%) for 38oC)
• Yes 1 (25%) 22 (55%)
• No 3 (75%) 18 (45%)
Vomiting
• Yes 2 (50%) 25 (62.5%)
Frequency of vomiting (episodes/day)
1-4 1 (50%)* 10 (40%)*
≥5 1 (50%)* 15 (60%)*
Duration of vomiting (days)
1 2 (100%)* 17 (68%)*
≥2 0 (0%)* 8 (32%)*
• No 2 (50%) 15 (37.5%)
Diarrhea
• Stool type
Watery 3 (75%) 17 (42.5%)
Mushy 1 (25%) 23 (57.5%)^
• Frequency of diarrhea (times/day)
3-9 2 (50%) 23 (57.5%)
≥10 2 (50%) 17 (42.5%)
• Duration of diarrhea (days)
1-4 4 (100%) 34 (85%)
≥5 0 (0%) 6 (15%)
Abdominal pain
• Yes 4 (100%) 36 (90%)
• No 0 (0%) 4 (10%)
Dehydration
• No dehydration 4 (100%) 32 (80%)
• Mild to moderate dehydration 0 (0%) 8 (20%)
* The percentage was calculated using the number of patients with vomiting only as a denominator ^ 1 patient have
mushy and bloody stool type1434 Indian Journal of Public Health Research & Development, June 2020, Vol. 11, No. 6
Fig 1. Neighbor-joining phylogenetic tree of partial sequences of the capsid (VP1) of 1 NoV GI isolate from Jambi
(shown in bold) and 10 reference strainsIndian Journal of Public Health Research & Development, June 2020, Vol. 11, No. 6 1435
Fig 2. Neighbor-joining phylogenetic tree of partial sequences of the capsid (VP1) of 3 NoV GII isolates from Jambi (shown in
bold) and 24 reference strains
Discussion The percentage of GII NoV (75%) strains detected
was greater than GI NoV (25%). It confirmed the
In this study, the proportion of NoV in adults with
previous report that GII NoV was the most prevalent
AGE was 9.1% in Jambi, quite similar to that in the
(96%) of all sporadic AGE worldwide.(19) Our study
≥12 years with AGE in Jakarta, Indonesia (9.7%)(9),
identified GI.2, GII.3, and GII.20 genotypes which have
but more than that in asymptomatic aduls in Surabaya,
never been reported in Indonesia, and GII.6 genotype
Indonesia (2.7%)(11). However, the rate was lower than
which has already been reported previously in children
the previous studies in China, United States, and France1436 Indian Journal of Public Health Research & Development, June 2020, Vol. 11, No. 6
In other countries, NoVs with genotypes GI.2, Acknowledgment: The authors are grateful to all
GII.3, GII.6, and GII.20 have been reported. Norovirus participants who provided stool specimens for supporting
GI.2 emerged in Singapore in 2014 causing outbreaks the specimen collection.
of NoV AGE in military camps.(21) This genotype was
also reported in ice-associated NoV outbreak in Taiwan, Conflict of Interest: There was no conflict of
2015. Norovirus GI was reported more predominant interest in this study.
in waterborne outbreaks.(22) Genotype GII.3 is a Ethics Statement: The ethical clearance was
major cause of sporadic gastroenteritis, particularly in obtained from the Ethics Committees of Faculty of
children(23) and it was identified also as a causative agent Medicine and Health Science, Universitas Jambi,
of gastroenteritis outbreaks in China (24) and Australia. Indonesia (No. B/248/UN21.8/PT.01.04/2019).
(25) Genotype GII.20 was reported in a small number
Informed consent was provided by the parents or
among gastroenteritis cases in Thailand in 2007 and guardians of each child’ to patients.
Australia during 2013-2014.(26,27) GII.6 is one of the
common agents of gastroenteritis.(28) An AGE outbreak Source of Funding: This study was supported by a
caused by NoV GII.6 was first reported in China in 2013. grant from Faculty of Medicine, Universitas Airlangga.
(29)
In 2015, GII.6 accounted for 10% of NoV infections,
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