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. 2016 May 15;62(10):1210-7.
doi: 10.1093/cid/ciw072. Epub 2016 Mar 24.

Norovirus Infection and Acquired Immunity in 8 Countries: Results From the MAL-ED Study

Saba Rouhani  1 , Pablo Peñataro Yori  2 , Maribel Paredes Olortegui  3 , Mery Siguas Salas  3 , Dixner Rengifo Trigoso  3 , Dinesh Mondal  4 , Ladaporn Bodhidatta  5 , James Platts-Mills  6 , Amidou Samie  7 , Furqan Kabir  8 , Aldo Lima  9 , Sudhir Babji  10 , Carl J Mason  5 , Adil Kalam  8 , Pascal Bessong  8 , Tahmeed Ahmed  4 , Estomih Mduma  11 , Zulfiqar A Bhutta  8 , Ila Lima  9 , Rakhi Ramdass  10 , Dennis Lang  12 , Ajila George  10 , Anita K M Zaidi  8 , Gagandeep Kang  10 , Eric Houpt  6 , Margaret N Kosek  1 ; Etiology, Risk Factors, and Interactions of Enteric Infections and Malnutrition and the Consequences for Child Health and Development Project (MAL-ED) Network Investigators
Collaborators, Affiliations

Norovirus Infection and Acquired Immunity in 8 Countries: Results From the MAL-ED Study

Saba Rouhani et al. Clin Infect Dis. .

Abstract

Background: Norovirus is an important cause of childhood diarrhea. We present data from a longitudinal, multicountry study describing norovirus epidemiology during the first 2 years of life.

Methods: A birth cohort of 1457 children across 8 countries contributed 7077 diarrheal stools for norovirus testing. A subset of 199 children contributed additional asymptomatic samples (2307) and diarrheal stools (770), which were used to derive incidence rates and evaluate evidence for acquired immunity.

Results: Across sites, 89% of children experienced at least 1 norovirus infection before 24 months, and 22.7% of all diarrheal stools were norovirus positive. Severity of norovirus-positive diarrhea was comparable to other enteropathogens, with the exception of rotavirus. Incidence of genogroup II (GII) infection was higher than genogroup I and peaked at 6-11 months across sites. Undernutrition was a risk factor for symptomatic norovirus infection, with an increase in 1 standard deviation of length-for-age z score associated with a 17% reduction (odds ratio, 0.83 [95% confidence interval, .72-.97]; P = .011) in the odds of experiencing diarrhea when norovirus was present, after accounting for genogroup, rotavirus vaccine, and age. Evidence of acquired immunity was observed among GII infections only: Children with prior GII infection were found to have a 27% reduction in the hazard of subsequent infection (hazard ratio, 0.727; P = .010).

Conclusions: The high prevalence of norovirus across 8 sites in highly variable epidemiologic settings and demonstration of protective immunity for GII infections provide support for investment in vaccine development.

Keywords: diarrhea; immunity; norovirus.

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Figures

Figure 1.
Figure 1.
Cumulative incidence of norovirus infection, by genogroup (GI and GII) and country: Abbreviations: BGD, Bangladesh; BRF, Brazil; INV, India; NEB, Nepal; PEL, Peru; PKN, Pakistan; SAV, South Africa; TZH, Tanzania.
Figure 2.
Figure 2.
Prevalence of norovirus genogroup I (GI) and genogroup II (GII) in routine and diarrheal stool samples, by month of age. Blue: diarrheal stools; red: surveillance stools.
Figure 3.
Figure 3.
Proportion of norovirus genogroup I (GI) and genogroup II (GII)–positive stools. Blue: GI; red: GII; green: GI/GII coinfection. Abbreviations: BG, Bangladesh; BR, Brazil; IN, India; NP, Nepal; NRV, norovirus; PE, Peru; PK, Pakistan; SA, South Africa; TZ, Tanzania.
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