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Detection and Comparison of Sapovirus, Rotavirus and Norovirus

Detection and Comparison of Sapovirus, Rotavirus and Norovirus

Abdulazeez et al (2020): Detection and comparison of in acute Oct 2020 Vol. 23 Issue 14

Detection and comparison of , and among infants and young children with acute gastroenteritis Mariam Sami Abdulazeez1, Arwa Mujahid Al-Shuwaikh2*, Ismail Ibrahim Latif3

1B.Sc, Microbiology Department, College of Medicine, University of Diyala, Iraq 2Ph.D, Assistant Prof, Microbiology Department, College of Medicine, Al-Nahrain University, Iraq, Email: [email protected] 3MBChB, PhD, Microbiology Department, College of Medicine, University of Diyala, Iraq

*Corresponding Author: Arwa Mujahid Al-Shuwaikh, Email: [email protected]

Abstract Background: Acute gastroenteritis (AGE) remains a global problem. Rotavirus (RV), norovirus (NoV) and Sapovirus (SV) are recognized as an important causes of AGE among children worldwide. However, there is no information about prevalence of Sapovirus in Iraq. Objective: To assess the frequency of SV, RV and NoV in children with AGE, also to determine the risk factors associated with the disease. Methods: A cross section study was carried out for 93 children under the age of five years old with AGE who attended to the Emergency Department of Pediatrics in Al-Batool Teaching Hospital for Maternity and Children in Baqubah city, Iraq, using real-time Polymerase Chain Reaction (RT-PCR) to determine the presence of human Sapovirus and -linked immunosorbent assay (ELISA) to evaluate the presence of human rotavirus and human norovirus . Results: The positive samples of SV were (6.5%). And the positive samples of RV and NoV were (79.6%) and (1.1%), respectively. Statistically, RV shows the higher positivity rate among viruses with significant difference (P<0.05). The present study showed that all SV and NoV cases were co- infected with RV. In addition, the present study showed that there was no statistically significant association between viruses positivity and the different sources of water, the level of mother education and clinical features (P>0.05). Conclusion: RV can be consider one of the most causes of in children and more research are required to investigate the role of SV as a primary etiology of pediatric diarrhea.

Keywords: Viral infection, gastroenteritis, children, Real Time PCR, ELISA, Iraq

How to cite this article: Abdulazzez MS, Al-Shuwaikh AM, Latif II (2020): Detection and comparison of Sapovirus, rotavirus among infants and young children with acute gastroenteritis, Ann Trop Med & Public Health; 23(S14): SP231439. DOI: http://doi.org/10.36295/ASRO.2020.231439

List of abbreviation: SV, Sapovirus; RV, rotavirus; NoV, norovirus; AGE, acute gastroenteritis

Introduction Diarrhea is the second greatest cause of mortality in children under 5 years of age worldwide (Anderson et al., 2010), with 10% deaths each year. Among the etiologic agents of diarrhea, viruses lead the way with 80% of cases. Among these viruses, (RV) are the most represented (Agbla et al., 2018). Rotaviruses were first identified in humans in 1973 when characteristic particles were observed in the cytoplasm of duodenal epithelial cells obtained from young children admitted to the hospital for treatment of acute diarrhea (Bishop, 1996). Rotaviruses are non-enveloped, icosahedra, double-stranded RNA viruses comprising a within the family (Dennehy, 2015; Crawford et al., 2017). In 2009, the World Health Organization (WHO) recommended that all countries introduce rotavirus into their national programs (World Health Organization, 2009). Enteric Calciviruses in the genera norovirus (NoV) and Sapovirus (SV) are significant causes of gastroenteritis in humans and animals, with alone causing approximately 200,000 deaths per annum in children <5 years of age (Patel et al., 2009; Ayukekbong, 2015; Alfajaro et al., 2017). However, in countries where universal rotavirus has been implemented, noroviruses have become most prevalent in children admitted to hospital with acute gastroenteritis (AGE) (Patel et al., 2009; Ayukekbong et al., 2015). NoV was first recorded in the American town of Norwalk, Ohio after outbreak at a primary school in the town among children and staff. The infection was just distinguished in 1972 after the assessment of tests from the incident. It was then named Norwalk infection (Lindesmith et al., 2003). The name norovirus was approved in 2002 (Mayo, 2002). Human noroviruses are positive-strand RNA, non- enveloped viruses (Li et al., 2018). Symptomatic norovirus are common within different populations; this renders clinical judgment on its contribution to diarrhoeal disease difficult (Ayukekbong et al., 2015). Sapovirus, formerly known as Sapporo-like viruses, is a significant leading cause of gastroenteritis. Sapovirus particles were first identified in human diarrheic stool samples in 1976 in the United Kingdom by electron microscopy (Yinda et al., 2017). The prototype of SV was first detected in an outbreak of gastroenteritis in an infant’s home in Sapporo, Japan in 1977 (Chiba et al., 1979). SV is a single-stranded positive sense RNA .

Annals of Tropical Medicine & Public Health http://doi.org/10.36295/ASRO.2020.231439

Abdulazeez et al (2020): Detection and comparison of viruses in acute gastroenteritis Oct 2020 Vol. 23 Issue 14

The virions are composed of a single structural , with icosahedra symmetry (Romani et al., 2012), the prevalence of Sapovirus in children <5 years of age ranges from 3.3 to 17% (Diez-Valcarce et al., 2018). SV peaks in the winter and is relatively common among infants and toddlers, with almost all children having antibody against Sapovirus by the age of 5 years, while norovirus tends to be more common in older children (Anderson, 2010). Although earlier reports described SV infection as one with less severe clinical symptoms than norovirus and rotavirus, more recent studies have shown that infections with SV can result in hospitalizations and severe (Diez-Valcarce et al., 2018). The aim of this study is to determine the prevalence of rotaviruses, norovirus and Sapovirus in AGE in Baqubah city, Iraq. Materials and Methods Specimen collection: This cross section study was carried out on children with AGE who admitted to Emergency Department of Pediatrics in Al-Batool Teaching Hospital for Maternity and Children in Baqubah city during the period from 31 October till 22 December, 2019. Stool samples were collected from 93 children with AGE; 57 were males and 36 were females; their ages were ranged from one month to 60 months. For molecular test, stool samples were mixed with 500μl Tris-EDTA buffer (Promega, USA), vortex intensely and centrifuged at 5000 rpm for one minute and then the supernatant was collected and stored frozen at (-80°C) until tested by Real Time PCR (RT-PCR).While for serological tests, samples were collected and divided into two aliquots and stored frozen at (-20) until tested by Enzyme Linked Immunosorbent Assay (ELISA). This study was done after taken the approval of the Ethical Committee at College of Medicine - University of Diyala. Molecular detection of SV by RT-PCR: RNA extraction: The RNA extraction of Sapovirus was done using Maxwell® 16 Viral Total Nucleic Acid Purification Kit (Promega, USA) according to the manufacturer instructions. Internal Control (IC) was used in the extraction procedure which serves as an amplification control for each individually processed specimen and to identify possible reaction inhibition. The extracted RNA was stored frozen at (−70°C) until analysis. Sapovirus RNA amplification: The extracted RNA was transcribed into cDNA by a , followed by PCR using direct, qualitative one-step real time PCR. Reactions mix was prepared according to the manufacturer's instructions using RIDA® Sapovirus RT-PCR (R-Biopharm, Germany). RT-PCR was performed with the Mic Qpcr Cycler (Bio Molecular System, Australia) using primers and probe sequences that amplified a specific Sapovirus gene (ORF1).Positive and negative controls were included to verify the validation of the reaction instrument setting according to manufacture instruction for roter type instruments. The real-time thermal condition included reverse transcription step for 10 minutes at 58°C, followed by initial denaturation step for 1 minute at 95°C, then cycling step including 45 cycles of 95°C for 15 second and 60°C for 30 second with fluorescence data collected during the annealing/extension step. Fluorescence was detected in Green and Yellow detection channels for Sapovirus and IC, respectively on Qiagen Rotor-Gene Q. The results were interpreted by the software of Real Time PCR instrument according to manufacturer. Serological detection of RV and NoV by ELISA: Ninety three samples were tested for RV and NoV by using RIDASCREEN® Rotavirus Kit and RIDASCREEN® Norovirus 3rd generation Kit (R-Biopharm, Germany), respectively. Both kits employ monoclonal antibodies (mcAb) in a sandwich type method. In RV detection kit, amcAb to the product of the 6th viral gene (VP6) is coated to the surface of the microwell plate. This is a group specific that is found in all rotaviruses that cause disease in humans. While in NoV detection kit, the well surface of the microwell plate is coated with specific antibodies to the norovirus antigens of several different genotypes. The procedure was done following manufacturer's instructions. For sample preparation, stool samples were diluted (1:11) before adding into the microwell plate by adding 100μl (100 mg) of stool to 1 ml of sample diluents which supplied with the Kit. The stool suspension was homogenized by vortex mixer and then let the suspension stand for 10 minutes to allow coarse stool particles to settle and clarify the supernatant. After that, supernatant was centrifuged at 2500g for 5 minutes and the supernatant was used directly in the test. Blank, positive and negative control was included when the Kit was run. The optical densities (O.D.) of each well were measured at wave length 450 nm. The cut off value equals the absorbance of negative control plus 0.15. The calculated absorptions of the samples were compared with the cut off value. If the extinction rate of the sample is more than 10 % higher than the calculated cut-off value, the test sample was considered positive. Samples with extinctions more than 10 % below the calculated cut-off considered as negative. Statistical analysis Data of current study were analyzed by using statistical package for social studies SPSS version 22.0 (Chicago, IL, USA).Categorical variables was compared by chi-squared test (χ2). A level of P values ≤0.05 was considered statistically significant. Results Viral infection and co-infection Result of current study show positivity of SV, RV and NoV in patients with high significant different (P<0.05), where the RV recorded the highest viral infection (79.6%), then SV (6.45%) and lowest viral infection was for NoV (1.10%), in additionally, the viral co-infection was highest for SV versus RV (6.5%) and lowest for RV versus NoV (1.1%). SV versus NoV not recorded any co-infection, as shown in table (1).

Annals of Tropical Medicine & Public Health http://doi.org/10.36295/ASRO.2020.231439

Abdulazeez et al (2020): Detection and comparison of viruses in acute gastroenteritis Oct 2020 Vol. 23 Issue 14

Table (1): Frequency and percentage of viral infection and co-infection

Viral infection Count (%) Total (%) P value Positive (%) 6 (6.5%) SV 93 (100%) <0.001** Negative (%) 87 (93.5%) Positive (%) 74 (79.6%) RV 93 (100%) <0.001** Negative (%) 19 (20.4%) Positive (%) 1 (1.1%) NoV 93 (100%) <0.001** Negative (%) 92 (98.9%) Viral co-infection Count (%) Total (%) P value SV & RV 6 (6.5%) 93 (100%) 0.014* SV & NoV 0 (0%) 93 (100%) 1 RV & NoV 1(1.1%) 93 (100%) <0.001** * Significant difference (P<0.05), ** highly significant difference (P<0.001) Demographic, risk factors and clinical characteristics: There was significant difference (P<0.05) noticed between male and female as their rates of infection were (10.5%) and (0%), respectively in Sapovirus cases and (80.7%) and (77.8%), respectively in rotavirus cases but this difference was not statistically significant (P˃0.05). While the only norovirus positive case was male (1.8%) and none of female were positive, as shown in table (2). The highest infection rate was recorded among children in age group (6-12) months in Sapovirus and rotavirus (8.2%), (90.0%), respectively, although, norovirus positivity was detected only in one child (6.3%) in age group (>12) months. However, there was statistically significant association only between rotavirus positivity and the different age group (P<0.05), table (2). The distribution of positive Sapovirus and norovirus infection regarding the sources of water use, the highest infection rate was noticed among patients were used boiled filtered water (10.6%), (2.2%), respectively, while the highest infection rate among patients with rotavirus infection was noticed in those who used boiled bottled water (82.9%) followed by boiled filtered water (78.8%). However, there was no statistically significant association between viruses positivity and the different sources of water used (P>0.05). In addition, the present study showed that there was no significant association between Sapovirus, rotavirus and norovirus infection and the level mother education (P>0.05), as shown on table (2). Regarding the of human Sapovirus infection, 6 (100%) had diarrhea, 5(83.3%) had dehydration, 5(83.3%) had , 5(83.3%) had abdominal pain and 5(83.3%) had . While the most frequent clinical signs and symptoms among patients with human rotavirus infection were diarrhea 74 (100%), vomiting 60 (81.1%), abdominal pain 58 (78.4 %), fever 61 (82.4%) and dehydration 52 (70.3%). Generally only one child affected with norovirus, the signs and symptoms in this patient was include diarrhea, dehydration, vomiting, abdominal pain and fever1(100%).There was no statistically significant association between virus positivity and the clinical signs and symptoms (P˃0.05), as shown in table (2). Table (2): Distribution of viral infection according to gender, age, source of water, education level of mother and clinical signs and symptoms * Significant difference (P<0.05)

Annals of Tropical Medicine & Public Health http://doi.org/10.36295/ASRO.2020.231439

Abdulazeez et al (2020): Detection and comparison of viruses in acute gastroenteritis Oct 2020 Vol. 23 Issue 14

Parameter Total (%) SV (%) RV (%) NoV (%) Male 57 (61.3%) 6 (10.5%) 46 (80.7%) 1 (1.8%) Gender Female 36 (38.7%) 0 (0%) 28 (77.8%) 0 (0%) Total 93 (100%) 6 (6.5%) 74 (79.6%) 1 (1.1%) Statistics P value = 0.044* 0.733 0.424 < 6 28 (30.1%) 1 (3.6%) 19 (67.9%) 0 (0%) Age Groups 6 – 12 49 (52.7%) 4 (8.2%) 45 (90.0%) 0 (0%) > 12 16 (17.2%) 1 (6.3%) 10 (66.7%) 1 (6.3%) /month(s) Total 93 (100%) 6 (6.5%) 74 (79.6%) 1 (1.1%) Statistics P value = 0.732 0.027* 0.088 Filtered water 8 (8.6%) 0 (0%) 2 (66.7%) 0 (0%) Type of Bottled water 3 (3.2%) 0 (0%) 2 (66.7%) 0 (0%) Drinking Boiled filtered 47 (50.6%) 5 (10.6%) 41 (78.8%) 1 (2.2%) Boiled bottled 35 (37.6%) 1 (2.9%) 29 (82.9%) 0 (0%) Water water waterTotal 93 (100%) 6 (6.5%) 74 (79.6%) 1 (1.1%) Statistics P value = 0.412 0.834 0.793 Primary 3 (5%) 3 (5%) 47 (77.0%) 0 (0%) Mother Secondary 1 (6.7%) 1 (6.7%) 11 (84.6%) 1 (6.7%) Tertiary 2 (11.1%) 2 (11.1%) 16 (84.2%) 0 (0%) Education Total 6 (6.5%) 6 (6.5%) 74 (79.6%) 1 (1.1) Statistics P value = 0.651 0.707 0.072 Parameter sample (n=93) SV (n=6) RV (n=74) NoV (n=1) Diarrhea 93 (100%) 6 (100.0%) 74 (100%) 1 (100%) Clinical Dehydration 65 (69.9%) 5 (83.3%) 52 (70.3%) 1 (100%) Signs & Vomiting 75 (80.6) 5 (83.3%) 60 (81.1%) 1 (100%) Abdominal pain 74 (79.6) 5 (83.3%) 58 (78.4%) 1 (100%) Symptoms Fever 78 (83.9) 5 (83.3%) 61 (82.4%) 1 (100%) Statistics P value = 0.998 0.983 1.000

Discussion Viral infection and co-infection The rate of SV infection was detected in (6.5%) of children with AGE, table (1), worldwide, SV frequency ranging between (0.3%) to (9.3%). It was related with sporadic cases and outbreaks of gastroenteritis (Romani et al., 2012). Also Varela et al. mentioned that most of the SV long-term studies worldwide have shown prevalence rates ranging from (2.2%) to (12.7%) (Varela et al., 2019).In addition, previous reports available from 41 documented studies in low- and middle- countries, have reported SV infections in (6.19%) ranging from (0.2%) to (39%) (Magwalivha et al., 2018). However, SV prevalence was reported to be slightly higher in a study done by (Romani et al., 2012) in Iran, who get the rate (11.9%). In contrast, SV prevalence was reported to be lower in a study done by (Sdiri-Loulizi et al., 2011) in Tunis, who get the rate (0.8%) and (Fazeli et al., 2016) in Iran, who get the rate (2.1%). The disparity in the finding of the different studies with the present study may be due to many reasons, including the difference in geographical area, volume specimen that included in the study, and the laboratory technique employed for detection these viruses (Salman, 2017). In the current result, RV was detected in 74 out of 93 (79.6%) stool samples while NoV was detected in only one (1.1%) sample, table (1).The obtained result of RV infection was higher than that reported by (Al-Shuwaikh, 2016) in Baghdad where rotavirus was found in 35 out of 188 (18.62%) stool samples by using ELISA technique among children less than 5 years old with AGE. Also, higher than the finding done by (Azeez and Alsakee, 2017) in Erbil, who get the rate (32.0%) and (Koroglu et al., 2011) in Turkey, who reported an infection rate of (52.7%). The current study findings may be due to that majority of children enrolled in this study not vaccinated according to their mother. In the first year of life, rotavirus can prevent up to (85% to 98%) of all RV severe illness episodes and (74% to 87%) of all rotavirus illness episodes (Thomas et al., 2014). In 2009, WHO recommended inclusion of RV vaccination in all national immunization programs, according to the local information RV vaccine used in Iraq later of 2013 that supposed decrease gastroenteritis caused by rotavirus (Al-Shuwaikh et al., 2015). On the other hand, the rate of rotavirus infection in this study was lower than that reported by (Salman, 2017) in Diyala who get the rate (93.88%). It is expected that the infection rate was more in patients living in rural area. In addition, it is expected that infection rate vary according to age of child, mother education, type of feeding and other socio-economic factors (Hussein et al., 2015). The lowest viral infection in this study was for NoV (1.1%), table (1). Similarly, the result of this study supported (Benmessaoud et al., 2015) in morocco who get the prevalence rate of NoV in (0.82%). Although data from Thailand showed similar rates of norovirus prevalence in patients with AGE of all age groups ranged from (0.09% to 44.7%) (Kumthip etal, 2018). In contrast, NoV prevalence in the current study was lower than a recent study from Diyala done by (Diraa, 2019) that reported the presence of NoVin (6.04%) among children with gastroenteritis. In addition, in an earlier study done by (Sdiri-loulizi et al., 2008) in Tunisia reported an infection rate of Sapovirus, norovirus and rotavirus (1.0%), (17.4%) and (22.5%), respectively. The differences in the results reported worldwide among various studies due to the use of fresh or frozen stool specimens, the collection of samples in different seasons, the age of patients, period of the study, the methods

Annals of Tropical Medicine & Public Health http://doi.org/10.36295/ASRO.2020.231439

Abdulazeez et al (2020): Detection and comparison of viruses in acute gastroenteritis Oct 2020 Vol. 23 Issue 14

used in detection, using different kits for the same method and social behaviors of the population, e.g. personal hygiene, and/or environmental variations (Al-Shuwaikh, 2016). In present study, all mixed infections were found to be a combination of two viruses one of them RV. The viral co-infection was highest for SV versus RV (6.45%) and lowest for RV versus NoV (1.1%), table (1). While no mixed infections of NoV versus SV were recorded. SV are often reported to cause mixed infections with other enteric . High rates of co- infections were reported in previous study from India in (61%) (Rachakonda et al., 2008). In similar recent study done by (Tandukar et al., 2019) were reported high rates of enteric viruses co-infections (64%) in children suffering from diarrhea. RV appeared as the most frequent mixed infection. The high prevalence of co- infections might be due to the fact that these pathogens share same mode of acquisition and ultimately susceptibility is increased following a primary. Co-infections can be acquired from a common source or a new infection can occur while shedding from a previous infection is not still over (Binnicker, 2015). Demographic, risk factor and clinical characteristics The current result shows that all SV positive cases were males and there was statistically significant association between SV infection and gender (P<0.05). But there is no statistical significant association between the infection with RV or NoV and gender, table (2). However, several studies reported that there is no significant differences related with gender and SV, RV and NoV( Li-Juan et al, 2010; Fazeli et al., 2016; Biscaro et al., 2018). The explanation of male predominance may be due to social factors rather than a higher rate of infection (Al-Shuwaikh, 2016). This high prevalence associated with males can be due to the fact that male children are more active than females. In addition, they spend longer times outdoor and they have become more in contact with environmental factors than females. This make them more likely to infection than females(Hussein et al., 2016). According to the age of patients, the result of present study showed that SV and d RV revealed in higher percentage in age group (6-12) months compared to other age groups. However, there was no statistically significant association between viral infection and age group, table (2). This can be due to the fact that the maternal antibodies are only protective in the first few months of infant life because of their short half-life. As a result, this protection is missing when infants reach 6 months when the antibodies decrease, hence the rise in the number of viral gastroenteritis after 6 months(Hussein et al., 2016). There are many factors that contribute in of virus among these ages and important of these factors are the low health awareness and attention to personal hygiene for people with children, contamination of and water for consumption by virus and contamination of toys (Ahmed et al., 2004). All children in the current study were fed artificial bottle milk. Although, there was no statistical significant association between infection rate of SV, RV and NoV and the different sources of water used for milk perpetration, table (2).The water still considered as a source of transmission for these viruses. Generally, human enteric viruses are excreted in high concentrations in the feces of infected people and they have great potential to pollute water sources (Potgieter et al., 2020).In this study the highest rate of parents were used boiled filtered water may be because the filtered water is only used for filtration not for sterilization, also treated drinking water using chlorine, filtration, and boiling still not produced a guaranteed supply of water that is safe for drinking. In addition, storage of water in the household water tank may also be another potential source of contamination, due to microbial penetration of poorly maintained systems infection, also use of untreated water for other purposes, such as food preparation and bathing. The results of the current study may be explained by the method of boiling the water was not accurate (i.e. less than 100C), the milk bottle that was used after boiling phase for nutrition was not very clean or contaminated, or the use of untreated water for milk preparation (Diraa, 2019).In fact, breast milk not only provides infants with the safest and best food source, but also develop their immune systems and protects them from infection. It is thought that breast feeding provides some degree of protection against gastrointestinal pathogens via maternal antibodies, hormones that stimulate gastrointestinal development, anti-inflammatory , and white blood cells (Hadi, 2015).This may explain the high prevalence of rotavirus in the current study (79.6%) since all children included were fed artificial bottle milk, These findings are consistent with the findings of other studies (Clemens et al., 1993; Hussein, et al., 2015). Although the current study shows that the rate of infection was not significantly associated with level of mother education. These results may not reflect the exact picture of the role of mother education level due to small sample size tested. Several studies have shown that children from mothers who had no education or primary education only, have a higher risk of contracting infections. This may be due to the fact that children spend more time with their mothers, whose educational level may dictate the quality of care and the other social and environmental factors that a child may be exposed to various infections (Nakawesi et al., 2010; Hussein et al., 2015) A study done by (Andrews et al., 2017) find that having a college degree or higher is connected with seven of the thirteen healthy dietary behaviors, including greater attention to nutrition information. The high distribution of rotavirus reported in rural children could be attributable to child development-based unsanitary activities, home overcrowding, poor hygienic practices, negligence, and lack of public health services and education(Hussein et al., 2016). Interestingly, all the parents enrolled in this study deny their knowledge if their child vaccinated or not to rotavirus, therefore these information not included in this study. Out of 93 stool samples involved in this study 74 (79.6%) were found to have a viral infection either single or mixed, all mixed infections were found to be a combination of two viruses one of them rotavirus. Interestingly, all SV positive cases of the studied children were co-infected with RV and the only one Nov was found to be co-infected with RV, table (1). The most frequent clinical signs and symptoms among children with SV, RV and NoV were diarrhea, fever, vomiting, abdominal pain and dehydration. There was no statistically

Annals of Tropical Medicine & Public Health http://doi.org/10.36295/ASRO.2020.231439

Abdulazeez et al (2020): Detection and comparison of viruses in acute gastroenteritis Oct 2020 Vol. 23 Issue 14

significant association between different virus infection and the clinical signs and symptoms, table (2). It was reported that vomiting was the initial symptom in diarrheic children with RV gastroenteritis (Stephered, 1995) since RV infection is accompanied by abnormal gastric motor function, and this abnormality may be the cause of vomiting. Also most of children with RV were febrile, but only 14% had fever more than 39°C (Hussein et al., 2015). These clinical signs and symptoms are non-specific but highly suggestive and should raise the indexes of suspicion of infection with these viruses. Conclusion There is a high rate of human RV infection among children with AGE during the period of this study. The health care authorities need to set up an improved system for children's vaccination against RV as a compulsory preventive measure that is more efficient and much less cost-effective than traditional therapies. Further studies are required to investigate the role of Sapovirus in the pathogenesis of AGE in human from different age groups using larger sample size and considering a wider variety of risk factors.

Significance statement This study emphasis on the importance of development and implementation of practical guidelines and community education programs to help in prevention and control of viral gastroenteritis in Iraqi infants and young children Acknowledgments: The authors thank the administration of Al-Batool Teaching Hospital in Baquba for their kind approval and support to carry out the experiment of the present study. Contributors Mariam Sami Abdulazeez performed all the laboratory work and wrote the draft of this work, Dr. Arwa Mujahid Al-Shuwaikh supervised, design and wrote this manuscript, Dr. Ismail Ibrahim Latif supervised and involved in clinical aspect. All the authors have read and approved the final version of this manuscript. Competing interests The authors declare no conflicts of interests for this article. Funding: Self-funding.

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Annals of Tropical Medicine & Public Health http://doi.org/10.36295/ASRO.2020.231439

Abdulazeez et al (2020): Detection and comparison of viruses in acute gastroenteritis Oct 2020 Vol. 23 Issue 14

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