Intussusception Rate Aamong Uunder-Five-Children Before Introduction of Rotavirus Vaccine in North India

Intussusception Rate Aamong Uunder-Five-Children Before Introduction of Rotavirus Vaccine in... Abstract Background Baseline data on intussusception are needed to compare the intussusception rates following introduction of rotavirus vaccine. Methods A hospital-based bidirectional surveillance (retrospective from 2009 to 2012; and prospective from 2013 to 2015) was set up in a tertiary care hospital in Chandigarh, India, to enrol children <5 years of age admitted with intussusception as per Brighton’s classification, to estimate the hospital admission rate. Incidence of intussusception among infants and children <5 years of age was also estimated. Results A total of 277 intussusception cases (96 retrospective; 181 prospective) were reported. Majority of cases were males (69.7%) and infants (72%). Median age at diagnosis was 10 months (interquartile range 6–12 months). Nearly 62% cases were treated surgically and 33% radiologically. Incidence was estimated to be 20/100 000 infants, and 5/100 000 children <5 years of age per year, in Chandigarh. Conclusion Intussusception surveillance system provided background hospital admission and incidence rate before rotavirus vaccine introduction in North India. intussusception, surveillance, baseline, under-five children, rotavirus INTRODUCTION Over the past two decades, there has been a major effort to have a safe and effective rotavirus vaccine to prevent the significant morbidity and mortality associated with rotavirus infection, particularly in developing countries [1, 2]. A review of clinical trial and post-licensure vaccine effectiveness studies’ data from countries routinely using rotavirus vaccines in their national immunization programmes reported that rotavirus vaccines have reduced rotavirus hospitalizations by 49–92%, all-cause diarrhoea hospitalizations and deaths by 17–55 and 22–50%, respectively [2]. However, the first-generation rotavirus vaccines (e.g. RotaShield by Wyeth) have been associated with increased incidence of intussusceptions (1 excess case of intussusception per 10 000 vaccinated children) among children [3]. Hence, it was withdrawn within a year of its introduction. A meta-analysis by Rosillon et al. [4] has also reported an increased risk of intussusception during the first 7 days of administering the first dose of currently used rotavirus vaccines. In a recent study in the USA, increase in the intussusception hospitalization rates in children in 8–11 weeks is observed when data were compared pre- and post-rotavirus vaccine introduction [5]. This indicates that there is a need to set up an effective intussusception surveillance system in all the countries, which are deciding to introduce the rotavirus vaccine, or have recently introduced rotavirus vaccine in the national immunization schedule, like India (introduced in December 2015) [6, 7]. Surveillance system is required to know the background rate of intussusception cases before the vaccine introduction, and also to continue the surveillance for intussusception in all the catering hospitals so as to monitor the trend of intussusception cases after the introduction of rotavirus vaccine in the national immunization schedule. It is also important to monitor the variation in the clinical presentation and treatment outcomes, and epidemiology of intussusception among under-five children. Against this background, the present study was conducted with an objective of establishing a hospital-based surveillance system for intussusception in northern region of India, and also to estimate the incidence of intussusception among infants and under-five children in Chandigarh, a North Indian Union Territory (UT). METHODS The ethics committee of Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, had approved this study. It was conducted in a 2700-bedded tertiary care regional hospital, located in Chandigarh, which has a dedicated 250-bedded Advanced Pediatric Center (APC). Sick cases are referred to the study hospital and a medical college from the North Indian states (Punjab, Haryana, Himachal Pradesh, Jammu and Kashmir and Uttar Pradesh, including Uttarakhand) and UT, Chandigarh. Mild and sick cases are treated in the primary (n = 44) and secondary (n = 5) care settings, respectively, in the public sector [8]; or in the private clinics and hospitals (n = 4), in Chandigarh. However, intussusception cases are mostly referred to the study hospital, as it is the only hospital with a functional paediatric surgery department. A bidirectional surveillance system consisting of a retrospective (1 January 2009 to 31 December 2012) and a prospective (1 January 2013 to 31 December 2015) period was set up. The case definition of intussusception case was any hospitalized under-five-child meeting the Level 1 Brighton criteria, as presented in Supplementary File 1 [3]. Data of intussusception cases were obtained from the hospital records in Central Registration Department, APC, during retrospective period, and additionally from the emergency and paediatric surgery wards weekly, during prospective period. Background information on age, sex, demography, admission and discharge date, clinical symptoms and signs, diagnostics (abdominal ultrasonography), and treatment procedures performed was extracted and recorded on a pre-designed case record form. Data analysis Data were entered in an Excel sheet, and analysed using statistical package for social sciences (version 16). Descriptive analysis of the data was done to have the information on time trends, age, sex, and geographical distribution of cases. For estimating incidence rate of intussusception among infants (0–12 months) and children <5 years of age in Chandigarh, it was assumed that all the intussusception cases occurring in Chandigarh would report to the study hospital. However, retrospective period (2009–12) was excluded in the calculations, as some of the cases might have been missed in this period. Census (2011) population (1 054 686) was used as the base population in Chandigarh [9]. Growth rate (10–11%), as per Sample Registration System (SRS) data, was applied on the base population to get the estimates of the population from 2013 to 2015 [10]. Children <5 years of age were assumed to be 8% of the total population. Live births were estimated from the birth rate (14.7/1000 population). Infant mortality rate (21/1000 live births) was applied to estimate the number of infants in the corresponding years [10]. The estimated target number of under-five children was 114 701, and infants were 20 634 (Supplementary Table S1). The cumulative incidence rate was calculated as total number of intussusception cases among infants/under-five-children, admitted exclusively from Chandigarh, per 100 000 infants/under-five-children/year in Chandigarh. RESULTS A total of 277 children <5 years of age with intussusception [96 (34.7%) retrospective; 181(65.3%) prospective] were admitted in the study hospital in Chandigarh from 2009 to 2015. All the cases were enrolled in the study. Surgical criteria were used to label seven cases for which ultrasound findings were unavailable during the retrospective period. On an average, 24 cases (range 17–34) during the retrospective and 60 cases (range 56–67) during the prospective period were reported per year (Figure 1). Significantly (p = 0.008), higher proportion of cases (41%) was admitted during the summer months (May–July), as compared with the winter (25%) months (December–February) (Figure 2). Most of the intussusception cases were referred from Haryana (31.8%), Punjab (28.2%), and Himachal Pradesh (25.3%) (Figure 3). Fig. 1. View largeDownload slide Annual trend of intussusception cases among children <5 years of age from January 2009 to December 2015 in a tertiary hospital, Chandigarh. Fig. 1. View largeDownload slide Annual trend of intussusception cases among children <5 years of age from January 2009 to December 2015 in a tertiary hospital, Chandigarh. Fig. 2. View largeDownload slide Monthly distribution of intussusception cases among children <5 years of age from January 2009 to December 2015 at a tertiary hospital, Chandigarh. Fig. 2. View largeDownload slide Monthly distribution of intussusception cases among children <5 years of age from January 2009 to December 2015 at a tertiary hospital, Chandigarh. Fig. 3. View largeDownload slide Map showing the distribution of intussusception cases admitted in tertiary care hospital in Chandigarh from North Indian states, during 2009–15. Fig. 3. View largeDownload slide Map showing the distribution of intussusception cases admitted in tertiary care hospital in Chandigarh from North Indian states, during 2009–15. Majority (72%) of the intussusception cases were infants. Most of these infants were between 7 and 12 months (72%) (Table 1). The median age of diagnosis was 10 months (interquartile range 6–12 months). There was no statistical significant difference in the yearly trend of intussusception cases in different age groups (p = 0.517). About 70% of intussusception cases were males and 30% were females (Table 2). Table 1 Age- and sex-wise distribution of children <5 years of age diagnosed with intussusception in a tertiary care hospital in North India, from 2009 to 2015 Age in months  Sex   Retrospective period (n = 96)   Prospective period (n = 181)   Total Period (n = 277)   Male (%)  Female (%)  Total (%)  Male (%)  Female (%)  Total (%)  Male (%)  Female (%)  Total (%)  0–6  16 (50)  16 (50)  32 (33.3)  24 (35.3)  12 (17.7)  36 (19.8)  40 (58.9)  28 (41.1)  68 (24.5)  7–12  33 (73)  12 (27)  45 (46.8)  70 (80.5)  17 (19.5)  87 (48)  103 (78)  29 (22)  132 (47.5)  13–24  5 (55.5)  4 (44.5)  9 (9.3)  16 (72.7)  6 (27.3)  22 (12.1)  21 (67.7)  10 (32.3)  31 (11.2)  25–36  3 (75)  1 (25)  4 (4.1)  10 (47.6)  11 (52.4)  21 (11.6)  13 (52)  12 (48)  25 (9.0)  37–48  1 (33.3)  2 (66.7)  3 (3.1)  9 (81.8)  2 (18.2)  11 (6.0)  10 (71.4)  4 (28.6)  14 (5.0)  49–60  2 (66.7)  1 (33.3)  3 (3.1)  4 (100)  0  4 (2.2)  6 (85.7)  1 (14.3)  7 (2.5)  Total  60 (62.5)  36 (37.5)  96 (100)  133 (73.4)  48 (26.5)  181 (100)  193 (69.7)  84 (30.3)  277 (100)  Age in months  Sex   Retrospective period (n = 96)   Prospective period (n = 181)   Total Period (n = 277)   Male (%)  Female (%)  Total (%)  Male (%)  Female (%)  Total (%)  Male (%)  Female (%)  Total (%)  0–6  16 (50)  16 (50)  32 (33.3)  24 (35.3)  12 (17.7)  36 (19.8)  40 (58.9)  28 (41.1)  68 (24.5)  7–12  33 (73)  12 (27)  45 (46.8)  70 (80.5)  17 (19.5)  87 (48)  103 (78)  29 (22)  132 (47.5)  13–24  5 (55.5)  4 (44.5)  9 (9.3)  16 (72.7)  6 (27.3)  22 (12.1)  21 (67.7)  10 (32.3)  31 (11.2)  25–36  3 (75)  1 (25)  4 (4.1)  10 (47.6)  11 (52.4)  21 (11.6)  13 (52)  12 (48)  25 (9.0)  37–48  1 (33.3)  2 (66.7)  3 (3.1)  9 (81.8)  2 (18.2)  11 (6.0)  10 (71.4)  4 (28.6)  14 (5.0)  49–60  2 (66.7)  1 (33.3)  3 (3.1)  4 (100)  0  4 (2.2)  6 (85.7)  1 (14.3)  7 (2.5)  Total  60 (62.5)  36 (37.5)  96 (100)  133 (73.4)  48 (26.5)  181 (100)  193 (69.7)  84 (30.3)  277 (100)  Note: In total, 31 cases were reported in 5–10 years age group. Table 1 Age- and sex-wise distribution of children <5 years of age diagnosed with intussusception in a tertiary care hospital in North India, from 2009 to 2015 Age in months  Sex   Retrospective period (n = 96)   Prospective period (n = 181)   Total Period (n = 277)   Male (%)  Female (%)  Total (%)  Male (%)  Female (%)  Total (%)  Male (%)  Female (%)  Total (%)  0–6  16 (50)  16 (50)  32 (33.3)  24 (35.3)  12 (17.7)  36 (19.8)  40 (58.9)  28 (41.1)  68 (24.5)  7–12  33 (73)  12 (27)  45 (46.8)  70 (80.5)  17 (19.5)  87 (48)  103 (78)  29 (22)  132 (47.5)  13–24  5 (55.5)  4 (44.5)  9 (9.3)  16 (72.7)  6 (27.3)  22 (12.1)  21 (67.7)  10 (32.3)  31 (11.2)  25–36  3 (75)  1 (25)  4 (4.1)  10 (47.6)  11 (52.4)  21 (11.6)  13 (52)  12 (48)  25 (9.0)  37–48  1 (33.3)  2 (66.7)  3 (3.1)  9 (81.8)  2 (18.2)  11 (6.0)  10 (71.4)  4 (28.6)  14 (5.0)  49–60  2 (66.7)  1 (33.3)  3 (3.1)  4 (100)  0  4 (2.2)  6 (85.7)  1 (14.3)  7 (2.5)  Total  60 (62.5)  36 (37.5)  96 (100)  133 (73.4)  48 (26.5)  181 (100)  193 (69.7)  84 (30.3)  277 (100)  Age in months  Sex   Retrospective period (n = 96)   Prospective period (n = 181)   Total Period (n = 277)   Male (%)  Female (%)  Total (%)  Male (%)  Female (%)  Total (%)  Male (%)  Female (%)  Total (%)  0–6  16 (50)  16 (50)  32 (33.3)  24 (35.3)  12 (17.7)  36 (19.8)  40 (58.9)  28 (41.1)  68 (24.5)  7–12  33 (73)  12 (27)  45 (46.8)  70 (80.5)  17 (19.5)  87 (48)  103 (78)  29 (22)  132 (47.5)  13–24  5 (55.5)  4 (44.5)  9 (9.3)  16 (72.7)  6 (27.3)  22 (12.1)  21 (67.7)  10 (32.3)  31 (11.2)  25–36  3 (75)  1 (25)  4 (4.1)  10 (47.6)  11 (52.4)  21 (11.6)  13 (52)  12 (48)  25 (9.0)  37–48  1 (33.3)  2 (66.7)  3 (3.1)  9 (81.8)  2 (18.2)  11 (6.0)  10 (71.4)  4 (28.6)  14 (5.0)  49–60  2 (66.7)  1 (33.3)  3 (3.1)  4 (100)  0  4 (2.2)  6 (85.7)  1 (14.3)  7 (2.5)  Total  60 (62.5)  36 (37.5)  96 (100)  133 (73.4)  48 (26.5)  181 (100)  193 (69.7)  84 (30.3)  277 (100)  Note: In total, 31 cases were reported in 5–10 years age group. Table 2 Age-wise trend of intussusception cases among children <5 years of age in a tertiary care hospital in North India, from 2009 to 2015 Year  0–6  7–12  13–24  25–36  37–48  48–60  Total  N  N  N  N  N  N  N (%)  2009  9  9  4  1  1  1  25 (9)  2010  11  18  3  1  0  1  34 (12.2)  2011  8  11  0  1  0  0  20 (7)  2012  4  7  2  1  2  1  17 (6.1)  2013  15  25  6  8  3  1  58 (20)  2014  9  32  8  3  2  2  56 (20)  2015  12  30  8  10  6  1  67 (24)  Total N (%)  68 (24.5)  132 (47.5)  31 (11.2)  25 (9.0)  14 (5.0)  7 (2.5)  277 (100)  Year  0–6  7–12  13–24  25–36  37–48  48–60  Total  N  N  N  N  N  N  N (%)  2009  9  9  4  1  1  1  25 (9)  2010  11  18  3  1  0  1  34 (12.2)  2011  8  11  0  1  0  0  20 (7)  2012  4  7  2  1  2  1  17 (6.1)  2013  15  25  6  8  3  1  58 (20)  2014  9  32  8  3  2  2  56 (20)  2015  12  30  8  10  6  1  67 (24)  Total N (%)  68 (24.5)  132 (47.5)  31 (11.2)  25 (9.0)  14 (5.0)  7 (2.5)  277 (100)  Table 2 Age-wise trend of intussusception cases among children <5 years of age in a tertiary care hospital in North India, from 2009 to 2015 Year  0–6  7–12  13–24  25–36  37–48  48–60  Total  N  N  N  N  N  N  N (%)  2009  9  9  4  1  1  1  25 (9)  2010  11  18  3  1  0  1  34 (12.2)  2011  8  11  0  1  0  0  20 (7)  2012  4  7  2  1  2  1  17 (6.1)  2013  15  25  6  8  3  1  58 (20)  2014  9  32  8  3  2  2  56 (20)  2015  12  30  8  10  6  1  67 (24)  Total N (%)  68 (24.5)  132 (47.5)  31 (11.2)  25 (9.0)  14 (5.0)  7 (2.5)  277 (100)  Year  0–6  7–12  13–24  25–36  37–48  48–60  Total  N  N  N  N  N  N  N (%)  2009  9  9  4  1  1  1  25 (9)  2010  11  18  3  1  0  1  34 (12.2)  2011  8  11  0  1  0  0  20 (7)  2012  4  7  2  1  2  1  17 (6.1)  2013  15  25  6  8  3  1  58 (20)  2014  9  32  8  3  2  2  56 (20)  2015  12  30  8  10  6  1  67 (24)  Total N (%)  68 (24.5)  132 (47.5)  31 (11.2)  25 (9.0)  14 (5.0)  7 (2.5)  277 (100)  Overall, 22% cases presented with single, 36.4% with two, 25% with three, 27% with four, 4.3% with five, and 1.4% with six complaints (Table 3). The most common dual presentation was vomiting with abdominal pain (37.4%). The cases with history of abdominal distension (40 vs. 22.1%, p = 0.002), diarrhoea (7 vs. 1.1%, p = 0.005), vomiting (82.3 vs. 70.2%, p = 0.03), and complications (7 vs. 2.2%, p = 0.045) were significantly higher in the retrospective as compared with the prospective period. Also, there was significantly (p = 0.000) higher proportion of patients who had abdominal ultrasound done in the prospective as compared with retrospective period (100 vs. 92.7%). Age-wise clinical signs and symptoms are given in Table 4. Table 3 Clinical presentation of intussusception cases among children <5 years of age in a tertiary care hospital in North India, from 2009 to 2015 Number of complaints  Period   Complaints (number of cases)  Retrospective N (%)  Prospective N (%)  Total N (%)  One  22 (22.9)  39 (21.5)  61 (22)  Vomiting (23), abdominal pain (21), blood in stool (6), abdominal distention (6), fever (4), loose stool (1)  Two  29 (30.2)  72 (39.8)  101 (36.4)  Vomiting+abdominal pain (35), vomiting+blood in stool (21), vomiting+abdominal distention (11), vomiting+fever (5), vomiting+loose stool (4), vomiting+diarrhea (1), abdominal pain+blood in stool (11), abdominal pain+abdominal distention (3), abdominal pain+fever (3), abdominal pain+loose stool (4), blood in stool+abdominal distention (2), blood in stool+loose stool (1)  Three  33 (34.4)  36 (19.9)  70 (25.2)  Vomiting+abdominal pain+blood in stool (14), vomiting+abdominal pain+abdominal distention (5), vomiting+abdominal pain+fever (8), vomiting+abdominal pain+loose stool (1), vomiting+abdominal pain+diarrhea (2), vomiting+blood in stool+abdominal distention (10), vomiting+blood in stool+fever (4), vomiting+blood in stool+loose stool (2), vomiting+blood in stool+diarrhea (2), vomiting+abdominal distention+fever (6), vomiting+abdominal distention+loose stool (2), vomiting+abdominal distention+diarrhea (1), vomiting+abdominal distention+altered sensorium (1), vomiting+fever+loose stool (4), vomiting+fever+diarrhea (1), vomiting+fever+altered sensorium (1), abdominal pain+blood in stool+abdominal distention (2), abdominal pain+blood in stool+nausea (1), abdominal pain+abdominal distention+loose stool (1), abdominal pain+abdominal distention+diarrhea (1), abdominal pain+loose stool+blood in stool (1)  Four  8 (8.3)  20 (11.0)  27 (9.7)  Vomiting+abdominal pain+blood in stool+abdominal distention (4), vomiting+abdominal pain+blood in stool+fever (8), vomiting+abdominal pain+blood in stool+loose stool (3), vomiting+abdominal pain+blood in stool+diarrhea (1), vomiting+abdominal pain+abdominal distention+fever (6), vomiting+abdominal pain+fever+loose stool (1), vomiting+blood in stool+abdominal distention+loose stool (1), vomiting+blood in stool+fever+loose stool (1), vomiting+abdominal distention+fever+loose stool (1), abdominal pain+blood in stool+abdominal distention+fever (1)  Five  2 (2.1)  10 (5.5)  12 (4.3)  Vomiting+abdominal pain+blood in stool+abdominal distention+fever (7), vomiting+abdominal pain+blood in stool+abdominal distention+loose stool (2), vomiting+abdominal pain+blood in stool+fever+loose stool (2), vomiting+abdominal pain+abdominal distention+fever+loose stool (1)  Six  1 (1)  3 (1.7)  4 (1.4)  Vomiting+abdominal pain+blood in stool+abdominal distention+fever+loose stool (4)  None  1 (1)  1 (0.6)  2 (0.7)  –  Total cases  96 (34.6)  181 (65.3)  277 (100)    Number of complaints  Period   Complaints (number of cases)  Retrospective N (%)  Prospective N (%)  Total N (%)  One  22 (22.9)  39 (21.5)  61 (22)  Vomiting (23), abdominal pain (21), blood in stool (6), abdominal distention (6), fever (4), loose stool (1)  Two  29 (30.2)  72 (39.8)  101 (36.4)  Vomiting+abdominal pain (35), vomiting+blood in stool (21), vomiting+abdominal distention (11), vomiting+fever (5), vomiting+loose stool (4), vomiting+diarrhea (1), abdominal pain+blood in stool (11), abdominal pain+abdominal distention (3), abdominal pain+fever (3), abdominal pain+loose stool (4), blood in stool+abdominal distention (2), blood in stool+loose stool (1)  Three  33 (34.4)  36 (19.9)  70 (25.2)  Vomiting+abdominal pain+blood in stool (14), vomiting+abdominal pain+abdominal distention (5), vomiting+abdominal pain+fever (8), vomiting+abdominal pain+loose stool (1), vomiting+abdominal pain+diarrhea (2), vomiting+blood in stool+abdominal distention (10), vomiting+blood in stool+fever (4), vomiting+blood in stool+loose stool (2), vomiting+blood in stool+diarrhea (2), vomiting+abdominal distention+fever (6), vomiting+abdominal distention+loose stool (2), vomiting+abdominal distention+diarrhea (1), vomiting+abdominal distention+altered sensorium (1), vomiting+fever+loose stool (4), vomiting+fever+diarrhea (1), vomiting+fever+altered sensorium (1), abdominal pain+blood in stool+abdominal distention (2), abdominal pain+blood in stool+nausea (1), abdominal pain+abdominal distention+loose stool (1), abdominal pain+abdominal distention+diarrhea (1), abdominal pain+loose stool+blood in stool (1)  Four  8 (8.3)  20 (11.0)  27 (9.7)  Vomiting+abdominal pain+blood in stool+abdominal distention (4), vomiting+abdominal pain+blood in stool+fever (8), vomiting+abdominal pain+blood in stool+loose stool (3), vomiting+abdominal pain+blood in stool+diarrhea (1), vomiting+abdominal pain+abdominal distention+fever (6), vomiting+abdominal pain+fever+loose stool (1), vomiting+blood in stool+abdominal distention+loose stool (1), vomiting+blood in stool+fever+loose stool (1), vomiting+abdominal distention+fever+loose stool (1), abdominal pain+blood in stool+abdominal distention+fever (1)  Five  2 (2.1)  10 (5.5)  12 (4.3)  Vomiting+abdominal pain+blood in stool+abdominal distention+fever (7), vomiting+abdominal pain+blood in stool+abdominal distention+loose stool (2), vomiting+abdominal pain+blood in stool+fever+loose stool (2), vomiting+abdominal pain+abdominal distention+fever+loose stool (1)  Six  1 (1)  3 (1.7)  4 (1.4)  Vomiting+abdominal pain+blood in stool+abdominal distention+fever+loose stool (4)  None  1 (1)  1 (0.6)  2 (0.7)  –  Total cases  96 (34.6)  181 (65.3)  277 (100)    p = 0.149 Table 3 Clinical presentation of intussusception cases among children <5 years of age in a tertiary care hospital in North India, from 2009 to 2015 Number of complaints  Period   Complaints (number of cases)  Retrospective N (%)  Prospective N (%)  Total N (%)  One  22 (22.9)  39 (21.5)  61 (22)  Vomiting (23), abdominal pain (21), blood in stool (6), abdominal distention (6), fever (4), loose stool (1)  Two  29 (30.2)  72 (39.8)  101 (36.4)  Vomiting+abdominal pain (35), vomiting+blood in stool (21), vomiting+abdominal distention (11), vomiting+fever (5), vomiting+loose stool (4), vomiting+diarrhea (1), abdominal pain+blood in stool (11), abdominal pain+abdominal distention (3), abdominal pain+fever (3), abdominal pain+loose stool (4), blood in stool+abdominal distention (2), blood in stool+loose stool (1)  Three  33 (34.4)  36 (19.9)  70 (25.2)  Vomiting+abdominal pain+blood in stool (14), vomiting+abdominal pain+abdominal distention (5), vomiting+abdominal pain+fever (8), vomiting+abdominal pain+loose stool (1), vomiting+abdominal pain+diarrhea (2), vomiting+blood in stool+abdominal distention (10), vomiting+blood in stool+fever (4), vomiting+blood in stool+loose stool (2), vomiting+blood in stool+diarrhea (2), vomiting+abdominal distention+fever (6), vomiting+abdominal distention+loose stool (2), vomiting+abdominal distention+diarrhea (1), vomiting+abdominal distention+altered sensorium (1), vomiting+fever+loose stool (4), vomiting+fever+diarrhea (1), vomiting+fever+altered sensorium (1), abdominal pain+blood in stool+abdominal distention (2), abdominal pain+blood in stool+nausea (1), abdominal pain+abdominal distention+loose stool (1), abdominal pain+abdominal distention+diarrhea (1), abdominal pain+loose stool+blood in stool (1)  Four  8 (8.3)  20 (11.0)  27 (9.7)  Vomiting+abdominal pain+blood in stool+abdominal distention (4), vomiting+abdominal pain+blood in stool+fever (8), vomiting+abdominal pain+blood in stool+loose stool (3), vomiting+abdominal pain+blood in stool+diarrhea (1), vomiting+abdominal pain+abdominal distention+fever (6), vomiting+abdominal pain+fever+loose stool (1), vomiting+blood in stool+abdominal distention+loose stool (1), vomiting+blood in stool+fever+loose stool (1), vomiting+abdominal distention+fever+loose stool (1), abdominal pain+blood in stool+abdominal distention+fever (1)  Five  2 (2.1)  10 (5.5)  12 (4.3)  Vomiting+abdominal pain+blood in stool+abdominal distention+fever (7), vomiting+abdominal pain+blood in stool+abdominal distention+loose stool (2), vomiting+abdominal pain+blood in stool+fever+loose stool (2), vomiting+abdominal pain+abdominal distention+fever+loose stool (1)  Six  1 (1)  3 (1.7)  4 (1.4)  Vomiting+abdominal pain+blood in stool+abdominal distention+fever+loose stool (4)  None  1 (1)  1 (0.6)  2 (0.7)  –  Total cases  96 (34.6)  181 (65.3)  277 (100)    Number of complaints  Period   Complaints (number of cases)  Retrospective N (%)  Prospective N (%)  Total N (%)  One  22 (22.9)  39 (21.5)  61 (22)  Vomiting (23), abdominal pain (21), blood in stool (6), abdominal distention (6), fever (4), loose stool (1)  Two  29 (30.2)  72 (39.8)  101 (36.4)  Vomiting+abdominal pain (35), vomiting+blood in stool (21), vomiting+abdominal distention (11), vomiting+fever (5), vomiting+loose stool (4), vomiting+diarrhea (1), abdominal pain+blood in stool (11), abdominal pain+abdominal distention (3), abdominal pain+fever (3), abdominal pain+loose stool (4), blood in stool+abdominal distention (2), blood in stool+loose stool (1)  Three  33 (34.4)  36 (19.9)  70 (25.2)  Vomiting+abdominal pain+blood in stool (14), vomiting+abdominal pain+abdominal distention (5), vomiting+abdominal pain+fever (8), vomiting+abdominal pain+loose stool (1), vomiting+abdominal pain+diarrhea (2), vomiting+blood in stool+abdominal distention (10), vomiting+blood in stool+fever (4), vomiting+blood in stool+loose stool (2), vomiting+blood in stool+diarrhea (2), vomiting+abdominal distention+fever (6), vomiting+abdominal distention+loose stool (2), vomiting+abdominal distention+diarrhea (1), vomiting+abdominal distention+altered sensorium (1), vomiting+fever+loose stool (4), vomiting+fever+diarrhea (1), vomiting+fever+altered sensorium (1), abdominal pain+blood in stool+abdominal distention (2), abdominal pain+blood in stool+nausea (1), abdominal pain+abdominal distention+loose stool (1), abdominal pain+abdominal distention+diarrhea (1), abdominal pain+loose stool+blood in stool (1)  Four  8 (8.3)  20 (11.0)  27 (9.7)  Vomiting+abdominal pain+blood in stool+abdominal distention (4), vomiting+abdominal pain+blood in stool+fever (8), vomiting+abdominal pain+blood in stool+loose stool (3), vomiting+abdominal pain+blood in stool+diarrhea (1), vomiting+abdominal pain+abdominal distention+fever (6), vomiting+abdominal pain+fever+loose stool (1), vomiting+blood in stool+abdominal distention+loose stool (1), vomiting+blood in stool+fever+loose stool (1), vomiting+abdominal distention+fever+loose stool (1), abdominal pain+blood in stool+abdominal distention+fever (1)  Five  2 (2.1)  10 (5.5)  12 (4.3)  Vomiting+abdominal pain+blood in stool+abdominal distention+fever (7), vomiting+abdominal pain+blood in stool+abdominal distention+loose stool (2), vomiting+abdominal pain+blood in stool+fever+loose stool (2), vomiting+abdominal pain+abdominal distention+fever+loose stool (1)  Six  1 (1)  3 (1.7)  4 (1.4)  Vomiting+abdominal pain+blood in stool+abdominal distention+fever+loose stool (4)  None  1 (1)  1 (0.6)  2 (0.7)  –  Total cases  96 (34.6)  181 (65.3)  277 (100)    p = 0.149 Table 4 Age-wise signs and symptoms of intussusception cases among children <5 years of age in a tertiary care hospital in North India, during 2009–15 Age in months  Vomiting (%)  Abdominal pain (%)  Blood in stool (%)  Abdominal distention (%)  Fever (%)  Loose stool (%)  Diarrhea (%)  Altered sensorium (%)  Nausea (%)  0–12 (n=200)  79.0  46.5  45.5  32.0  24.9  14.4  4.0  0.5  0.5  13–24 (n=31)  64.5  74.2  25.8  19.4  19.4  12.9  0.0  3.2  0.0  25–36 (n=25)  56.0  72.0  20.0  20.0  24.0  12.0  4.0  0.0  0.0  37–48 (n=14)  64.3  92.9  35.7  28.6  21.4  7.1  0.0  0.0  0.0  49–60 (n=7)  71.4  71.4  28.6  0.0  42.9  14.3  0.0  0.0  0.0  Total (N=277)  74.4  54.9  40.1  28.5  24.5  13.7  3.2  0.7  0.4  Age in months  Vomiting (%)  Abdominal pain (%)  Blood in stool (%)  Abdominal distention (%)  Fever (%)  Loose stool (%)  Diarrhea (%)  Altered sensorium (%)  Nausea (%)  0–12 (n=200)  79.0  46.5  45.5  32.0  24.9  14.4  4.0  0.5  0.5  13–24 (n=31)  64.5  74.2  25.8  19.4  19.4  12.9  0.0  3.2  0.0  25–36 (n=25)  56.0  72.0  20.0  20.0  24.0  12.0  4.0  0.0  0.0  37–48 (n=14)  64.3  92.9  35.7  28.6  21.4  7.1  0.0  0.0  0.0  49–60 (n=7)  71.4  71.4  28.6  0.0  42.9  14.3  0.0  0.0  0.0  Total (N=277)  74.4  54.9  40.1  28.5  24.5  13.7  3.2  0.7  0.4  Table 4 Age-wise signs and symptoms of intussusception cases among children <5 years of age in a tertiary care hospital in North India, during 2009–15 Age in months  Vomiting (%)  Abdominal pain (%)  Blood in stool (%)  Abdominal distention (%)  Fever (%)  Loose stool (%)  Diarrhea (%)  Altered sensorium (%)  Nausea (%)  0–12 (n=200)  79.0  46.5  45.5  32.0  24.9  14.4  4.0  0.5  0.5  13–24 (n=31)  64.5  74.2  25.8  19.4  19.4  12.9  0.0  3.2  0.0  25–36 (n=25)  56.0  72.0  20.0  20.0  24.0  12.0  4.0  0.0  0.0  37–48 (n=14)  64.3  92.9  35.7  28.6  21.4  7.1  0.0  0.0  0.0  49–60 (n=7)  71.4  71.4  28.6  0.0  42.9  14.3  0.0  0.0  0.0  Total (N=277)  74.4  54.9  40.1  28.5  24.5  13.7  3.2  0.7  0.4  Age in months  Vomiting (%)  Abdominal pain (%)  Blood in stool (%)  Abdominal distention (%)  Fever (%)  Loose stool (%)  Diarrhea (%)  Altered sensorium (%)  Nausea (%)  0–12 (n=200)  79.0  46.5  45.5  32.0  24.9  14.4  4.0  0.5  0.5  13–24 (n=31)  64.5  74.2  25.8  19.4  19.4  12.9  0.0  3.2  0.0  25–36 (n=25)  56.0  72.0  20.0  20.0  24.0  12.0  4.0  0.0  0.0  37–48 (n=14)  64.3  92.9  35.7  28.6  21.4  7.1  0.0  0.0  0.0  49–60 (n=7)  71.4  71.4  28.6  0.0  42.9  14.3  0.0  0.0  0.0  Total (N=277)  74.4  54.9  40.1  28.5  24.5  13.7  3.2  0.7  0.4  Nearly 61.7% of the patients required surgical intervention, and 33% cases were resolved by the non-surgical interventions. Among those who required a non-surgical intervention, pneumatic reduction was possible in 75 (27%), conservative management in 14 (5%), barium reduction in 2 (0.7%) cases and laparoscopic reduction was done in 1 case (0.3%). In 14 (5%) cases, treatment procedure was not specified. There was no death reported because of intussusception. Average duration of stay in the hospital was 6 days. The most common location of intussusception was ileocolic region (77%), followed by ileoileal (7.9%), colocolic (4.7%), ileo-ileocolic (2.2%), and jejunojejunal (1.8%). Most of the intussusceptions were single (97.8%). The location of the intussusception in the patients who had non-surgical interventions (n = 91) was recorded from the ultrasound reports. There were six (2.1%) cases of secondary intussusception (two Meckel’s diverticulum, two ileal polyps, one malrotation of gut and one mesenteric cyst), and rest were idiopathic (98%). Incidence of intussusception in Chandigarh was estimated to be 20 cases per 100 000 infants per year (range 10–33/100 000 infants), and 5/100 000 children <5 years of age per year (range 4–7/100 000 under-five-children) (Supplementary Table 1). DISCUSSION The results of this study provided background estimates of hospital admission and incidence rate of intussusception among children <5 years of age in North India. These results are useful for the policymakers and programme implementers for comparison purposes following the introduction of rotavirus vaccination in national immunization schedule in India. Average number of intussusception cases (24 cases) reported in the retrospective period in this study is similar to a retrospective hospital-based study by Singh et al. [11] in Manipal (20 cases) and Lucknow (14 cases) in India. However, lack of incidence data in the Singh et al. [11] study prevented the comparison of the incidence rate with this study. The reasons for increase in intussusception rate (60/year vs. 24/year) during prospective (2013–15) as compared with the retrospective period (2009–12) could be the active mode of prospective surveillance, increased use of diagnostics (abdominal ultrasonography) or higher referral of intussusception cases during prospective surveillance. Prospective surveillance is considered to be a better method of surveillance for intussusception because of its completeness [12]. Hence, we have based the estimation of incidence of intussusception cases in Chandigarh on the data obtained in this period, and limited the discussion for this period only. Incidence of intussusception among infants as estimated in this study in Chandigarh (20 cases per 100 000 infant-years) is similar to that reported in Delhi (17.7 cases per 100 000 infant-years) by Bahl et al. [13] among infants. This may be because of the similar geographical area and prevalence of causative organisms for diarrhoea or infant-feeding practices in these two North Indian cities. Previous studies (2001–07) in developed countries have reported incidence rates of intussusception ranging from 30 to 130 cases per 100 000 infant-years [14–21]. Higher rates of intussusception in developed countries as compared with this study could be because of better study design (like cohort study) and better tracking and reporting of intussusception cases. In Vietnam, higher incidence of 302 cases per 100 000 infant-years was associated with adenovirus infection [22]. Summary of worldwide age-wise incidence of intussusception reported in the past 5 years, in the pre-rotavirus vaccination period, is given in Supplementary Table 2 [23–35]. The age at which maximum numbers of cases were recorded in this study was between 7 and 12 months, which is similar to other studies in India [11, 32] and abroad [29, 31]. The age-wise distribution of intussusception cases in this study (Table 1) is similar to Mandeville et al. [36] study. The increase in the median age of diagnosis from 7 months during the retrospective period to 12 months during the prospective period in this study is in line with the previous studies in developed countries [29, 37, 38]. The probable reason for the age shift has been related to delayed or reduced exposure to childhood infections arising from improving standards of hygiene and sanitation in these countries. However, we need high-quality long-term local surveillance to explore reasons for the same in developing nations. Similar male to female ratio (3:1) as observed in this study is also reported in previous studies in India [11, 39]. Although the ratio varies widely across different countries, there is predominance of males in previous studies also. The ratio varies from 1.3:1 in Singapore [19] to 9:1 in India [11, 40, 41]. Predominance of males in Indian settings could be because of sex-linked preferential treatment given to the sons as compared with the daughters [42, 43]. Seasonal variation in the intussusception cases is similar to other studies done in India [11] and abroad [19, 44, 45]. This trend also corresponds with the seasonality seen with acute diarrheal diseases, especially, in North India [46, 47]. However, no seasonal variation in the intussusception cases was reported in South India [39], and in Tanzania [44] and Latin America [27] abroad because of the different climatic conditions prevalent in different parts of India and abroad. Proportion of secondary intussusception cases (2%) among children <5 years of age as observed in this study is consistent with existing literature [48–51]. The clinical signs and symptoms of intussusception as reported in this study were similar to those reported previously in other studies [11, 32, 36, 39]. Similar differences in the clinical presentation in the retrospective and prospective period were also observed in a South Indian study [52]. This could be because of late presentation and management of cases in the retrospective as compared with prospective period. Most of the cases of intussusception were managed by surgical intervention as is also reported from other hospital-based surveillance study in India [11, 32]. However, surgical intervention was required in lower proportion of cases in this study (61.7%) as compared with previous study (71%) [11]. This could be because of more experience and advancement in technology to reduce intussusception by non-surgical methods [53]. The strength of this study is the use of standard case definition, reliable documentation and prospective surveillance design of intussusception cases. The cases of intussusception were ascertained by qualified, experienced and dedicated team of paediatric surgeon and radiologist, thereby ruling out error of miss-classification. Reporting of intussusception cases from paediatric surgery wards and emergency in addition to case record department had increased the chances of complete data capturing. This study strengthened the evidence on setting up of prospective intussusception surveillance in the country [52]. However, there are certain limitations in the study, such as history of rotavirus immunization was not obtained, as that was not the primary objective of the study, and also because rotavirus vaccine was not introduced in the universal immunization program during the study period (2009–15). As this was a hospital-based surveillance in a North Indian tertiary care hospital with no defined catchment area, estimation of state-specific incidence of cases of intussusception is not done, except for UT Chandigarh as this hospital was located in Chandigarh itself. However, the estimated incidence of intussusception in Chandigarh might also be an underestimation, as the cases that might have been treated in the private health facilities were missed. Future research may be planned to conduct longitudinal hospital-cum-community-based studies so as to have reliable estimates on the incidence and aetiology of intussusception, and also on the management of intussusception in the peripheral hospitals. SUPPLEMENTARY DATA Supplementary data are available at Journal of Tropical Pediatrics online. ACKNOWLEDGEMENTS The authors are thankful to resident doctors and nurses of Advanced Pediatric Center, and Department of Community Medicine, PGIMER, Chandigarh for data collection. 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Intussusception Rate Aamong Uunder-Five-Children Before Introduction of Rotavirus Vaccine in North India

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Oxford University Press
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© The Author [2017]. Published by Oxford University Press. All rights reserved. For Permissions, please email: journals.permissions@oup.com
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0142-6338
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1465-3664
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10.1093/tropej/fmx073
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Abstract

Abstract Background Baseline data on intussusception are needed to compare the intussusception rates following introduction of rotavirus vaccine. Methods A hospital-based bidirectional surveillance (retrospective from 2009 to 2012; and prospective from 2013 to 2015) was set up in a tertiary care hospital in Chandigarh, India, to enrol children <5 years of age admitted with intussusception as per Brighton’s classification, to estimate the hospital admission rate. Incidence of intussusception among infants and children <5 years of age was also estimated. Results A total of 277 intussusception cases (96 retrospective; 181 prospective) were reported. Majority of cases were males (69.7%) and infants (72%). Median age at diagnosis was 10 months (interquartile range 6–12 months). Nearly 62% cases were treated surgically and 33% radiologically. Incidence was estimated to be 20/100 000 infants, and 5/100 000 children <5 years of age per year, in Chandigarh. Conclusion Intussusception surveillance system provided background hospital admission and incidence rate before rotavirus vaccine introduction in North India. intussusception, surveillance, baseline, under-five children, rotavirus INTRODUCTION Over the past two decades, there has been a major effort to have a safe and effective rotavirus vaccine to prevent the significant morbidity and mortality associated with rotavirus infection, particularly in developing countries [1, 2]. A review of clinical trial and post-licensure vaccine effectiveness studies’ data from countries routinely using rotavirus vaccines in their national immunization programmes reported that rotavirus vaccines have reduced rotavirus hospitalizations by 49–92%, all-cause diarrhoea hospitalizations and deaths by 17–55 and 22–50%, respectively [2]. However, the first-generation rotavirus vaccines (e.g. RotaShield by Wyeth) have been associated with increased incidence of intussusceptions (1 excess case of intussusception per 10 000 vaccinated children) among children [3]. Hence, it was withdrawn within a year of its introduction. A meta-analysis by Rosillon et al. [4] has also reported an increased risk of intussusception during the first 7 days of administering the first dose of currently used rotavirus vaccines. In a recent study in the USA, increase in the intussusception hospitalization rates in children in 8–11 weeks is observed when data were compared pre- and post-rotavirus vaccine introduction [5]. This indicates that there is a need to set up an effective intussusception surveillance system in all the countries, which are deciding to introduce the rotavirus vaccine, or have recently introduced rotavirus vaccine in the national immunization schedule, like India (introduced in December 2015) [6, 7]. Surveillance system is required to know the background rate of intussusception cases before the vaccine introduction, and also to continue the surveillance for intussusception in all the catering hospitals so as to monitor the trend of intussusception cases after the introduction of rotavirus vaccine in the national immunization schedule. It is also important to monitor the variation in the clinical presentation and treatment outcomes, and epidemiology of intussusception among under-five children. Against this background, the present study was conducted with an objective of establishing a hospital-based surveillance system for intussusception in northern region of India, and also to estimate the incidence of intussusception among infants and under-five children in Chandigarh, a North Indian Union Territory (UT). METHODS The ethics committee of Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, had approved this study. It was conducted in a 2700-bedded tertiary care regional hospital, located in Chandigarh, which has a dedicated 250-bedded Advanced Pediatric Center (APC). Sick cases are referred to the study hospital and a medical college from the North Indian states (Punjab, Haryana, Himachal Pradesh, Jammu and Kashmir and Uttar Pradesh, including Uttarakhand) and UT, Chandigarh. Mild and sick cases are treated in the primary (n = 44) and secondary (n = 5) care settings, respectively, in the public sector [8]; or in the private clinics and hospitals (n = 4), in Chandigarh. However, intussusception cases are mostly referred to the study hospital, as it is the only hospital with a functional paediatric surgery department. A bidirectional surveillance system consisting of a retrospective (1 January 2009 to 31 December 2012) and a prospective (1 January 2013 to 31 December 2015) period was set up. The case definition of intussusception case was any hospitalized under-five-child meeting the Level 1 Brighton criteria, as presented in Supplementary File 1 [3]. Data of intussusception cases were obtained from the hospital records in Central Registration Department, APC, during retrospective period, and additionally from the emergency and paediatric surgery wards weekly, during prospective period. Background information on age, sex, demography, admission and discharge date, clinical symptoms and signs, diagnostics (abdominal ultrasonography), and treatment procedures performed was extracted and recorded on a pre-designed case record form. Data analysis Data were entered in an Excel sheet, and analysed using statistical package for social sciences (version 16). Descriptive analysis of the data was done to have the information on time trends, age, sex, and geographical distribution of cases. For estimating incidence rate of intussusception among infants (0–12 months) and children <5 years of age in Chandigarh, it was assumed that all the intussusception cases occurring in Chandigarh would report to the study hospital. However, retrospective period (2009–12) was excluded in the calculations, as some of the cases might have been missed in this period. Census (2011) population (1 054 686) was used as the base population in Chandigarh [9]. Growth rate (10–11%), as per Sample Registration System (SRS) data, was applied on the base population to get the estimates of the population from 2013 to 2015 [10]. Children <5 years of age were assumed to be 8% of the total population. Live births were estimated from the birth rate (14.7/1000 population). Infant mortality rate (21/1000 live births) was applied to estimate the number of infants in the corresponding years [10]. The estimated target number of under-five children was 114 701, and infants were 20 634 (Supplementary Table S1). The cumulative incidence rate was calculated as total number of intussusception cases among infants/under-five-children, admitted exclusively from Chandigarh, per 100 000 infants/under-five-children/year in Chandigarh. RESULTS A total of 277 children <5 years of age with intussusception [96 (34.7%) retrospective; 181(65.3%) prospective] were admitted in the study hospital in Chandigarh from 2009 to 2015. All the cases were enrolled in the study. Surgical criteria were used to label seven cases for which ultrasound findings were unavailable during the retrospective period. On an average, 24 cases (range 17–34) during the retrospective and 60 cases (range 56–67) during the prospective period were reported per year (Figure 1). Significantly (p = 0.008), higher proportion of cases (41%) was admitted during the summer months (May–July), as compared with the winter (25%) months (December–February) (Figure 2). Most of the intussusception cases were referred from Haryana (31.8%), Punjab (28.2%), and Himachal Pradesh (25.3%) (Figure 3). Fig. 1. View largeDownload slide Annual trend of intussusception cases among children <5 years of age from January 2009 to December 2015 in a tertiary hospital, Chandigarh. Fig. 1. View largeDownload slide Annual trend of intussusception cases among children <5 years of age from January 2009 to December 2015 in a tertiary hospital, Chandigarh. Fig. 2. View largeDownload slide Monthly distribution of intussusception cases among children <5 years of age from January 2009 to December 2015 at a tertiary hospital, Chandigarh. Fig. 2. View largeDownload slide Monthly distribution of intussusception cases among children <5 years of age from January 2009 to December 2015 at a tertiary hospital, Chandigarh. Fig. 3. View largeDownload slide Map showing the distribution of intussusception cases admitted in tertiary care hospital in Chandigarh from North Indian states, during 2009–15. Fig. 3. View largeDownload slide Map showing the distribution of intussusception cases admitted in tertiary care hospital in Chandigarh from North Indian states, during 2009–15. Majority (72%) of the intussusception cases were infants. Most of these infants were between 7 and 12 months (72%) (Table 1). The median age of diagnosis was 10 months (interquartile range 6–12 months). There was no statistical significant difference in the yearly trend of intussusception cases in different age groups (p = 0.517). About 70% of intussusception cases were males and 30% were females (Table 2). Table 1 Age- and sex-wise distribution of children <5 years of age diagnosed with intussusception in a tertiary care hospital in North India, from 2009 to 2015 Age in months  Sex   Retrospective period (n = 96)   Prospective period (n = 181)   Total Period (n = 277)   Male (%)  Female (%)  Total (%)  Male (%)  Female (%)  Total (%)  Male (%)  Female (%)  Total (%)  0–6  16 (50)  16 (50)  32 (33.3)  24 (35.3)  12 (17.7)  36 (19.8)  40 (58.9)  28 (41.1)  68 (24.5)  7–12  33 (73)  12 (27)  45 (46.8)  70 (80.5)  17 (19.5)  87 (48)  103 (78)  29 (22)  132 (47.5)  13–24  5 (55.5)  4 (44.5)  9 (9.3)  16 (72.7)  6 (27.3)  22 (12.1)  21 (67.7)  10 (32.3)  31 (11.2)  25–36  3 (75)  1 (25)  4 (4.1)  10 (47.6)  11 (52.4)  21 (11.6)  13 (52)  12 (48)  25 (9.0)  37–48  1 (33.3)  2 (66.7)  3 (3.1)  9 (81.8)  2 (18.2)  11 (6.0)  10 (71.4)  4 (28.6)  14 (5.0)  49–60  2 (66.7)  1 (33.3)  3 (3.1)  4 (100)  0  4 (2.2)  6 (85.7)  1 (14.3)  7 (2.5)  Total  60 (62.5)  36 (37.5)  96 (100)  133 (73.4)  48 (26.5)  181 (100)  193 (69.7)  84 (30.3)  277 (100)  Age in months  Sex   Retrospective period (n = 96)   Prospective period (n = 181)   Total Period (n = 277)   Male (%)  Female (%)  Total (%)  Male (%)  Female (%)  Total (%)  Male (%)  Female (%)  Total (%)  0–6  16 (50)  16 (50)  32 (33.3)  24 (35.3)  12 (17.7)  36 (19.8)  40 (58.9)  28 (41.1)  68 (24.5)  7–12  33 (73)  12 (27)  45 (46.8)  70 (80.5)  17 (19.5)  87 (48)  103 (78)  29 (22)  132 (47.5)  13–24  5 (55.5)  4 (44.5)  9 (9.3)  16 (72.7)  6 (27.3)  22 (12.1)  21 (67.7)  10 (32.3)  31 (11.2)  25–36  3 (75)  1 (25)  4 (4.1)  10 (47.6)  11 (52.4)  21 (11.6)  13 (52)  12 (48)  25 (9.0)  37–48  1 (33.3)  2 (66.7)  3 (3.1)  9 (81.8)  2 (18.2)  11 (6.0)  10 (71.4)  4 (28.6)  14 (5.0)  49–60  2 (66.7)  1 (33.3)  3 (3.1)  4 (100)  0  4 (2.2)  6 (85.7)  1 (14.3)  7 (2.5)  Total  60 (62.5)  36 (37.5)  96 (100)  133 (73.4)  48 (26.5)  181 (100)  193 (69.7)  84 (30.3)  277 (100)  Note: In total, 31 cases were reported in 5–10 years age group. Table 1 Age- and sex-wise distribution of children <5 years of age diagnosed with intussusception in a tertiary care hospital in North India, from 2009 to 2015 Age in months  Sex   Retrospective period (n = 96)   Prospective period (n = 181)   Total Period (n = 277)   Male (%)  Female (%)  Total (%)  Male (%)  Female (%)  Total (%)  Male (%)  Female (%)  Total (%)  0–6  16 (50)  16 (50)  32 (33.3)  24 (35.3)  12 (17.7)  36 (19.8)  40 (58.9)  28 (41.1)  68 (24.5)  7–12  33 (73)  12 (27)  45 (46.8)  70 (80.5)  17 (19.5)  87 (48)  103 (78)  29 (22)  132 (47.5)  13–24  5 (55.5)  4 (44.5)  9 (9.3)  16 (72.7)  6 (27.3)  22 (12.1)  21 (67.7)  10 (32.3)  31 (11.2)  25–36  3 (75)  1 (25)  4 (4.1)  10 (47.6)  11 (52.4)  21 (11.6)  13 (52)  12 (48)  25 (9.0)  37–48  1 (33.3)  2 (66.7)  3 (3.1)  9 (81.8)  2 (18.2)  11 (6.0)  10 (71.4)  4 (28.6)  14 (5.0)  49–60  2 (66.7)  1 (33.3)  3 (3.1)  4 (100)  0  4 (2.2)  6 (85.7)  1 (14.3)  7 (2.5)  Total  60 (62.5)  36 (37.5)  96 (100)  133 (73.4)  48 (26.5)  181 (100)  193 (69.7)  84 (30.3)  277 (100)  Age in months  Sex   Retrospective period (n = 96)   Prospective period (n = 181)   Total Period (n = 277)   Male (%)  Female (%)  Total (%)  Male (%)  Female (%)  Total (%)  Male (%)  Female (%)  Total (%)  0–6  16 (50)  16 (50)  32 (33.3)  24 (35.3)  12 (17.7)  36 (19.8)  40 (58.9)  28 (41.1)  68 (24.5)  7–12  33 (73)  12 (27)  45 (46.8)  70 (80.5)  17 (19.5)  87 (48)  103 (78)  29 (22)  132 (47.5)  13–24  5 (55.5)  4 (44.5)  9 (9.3)  16 (72.7)  6 (27.3)  22 (12.1)  21 (67.7)  10 (32.3)  31 (11.2)  25–36  3 (75)  1 (25)  4 (4.1)  10 (47.6)  11 (52.4)  21 (11.6)  13 (52)  12 (48)  25 (9.0)  37–48  1 (33.3)  2 (66.7)  3 (3.1)  9 (81.8)  2 (18.2)  11 (6.0)  10 (71.4)  4 (28.6)  14 (5.0)  49–60  2 (66.7)  1 (33.3)  3 (3.1)  4 (100)  0  4 (2.2)  6 (85.7)  1 (14.3)  7 (2.5)  Total  60 (62.5)  36 (37.5)  96 (100)  133 (73.4)  48 (26.5)  181 (100)  193 (69.7)  84 (30.3)  277 (100)  Note: In total, 31 cases were reported in 5–10 years age group. Table 2 Age-wise trend of intussusception cases among children <5 years of age in a tertiary care hospital in North India, from 2009 to 2015 Year  0–6  7–12  13–24  25–36  37–48  48–60  Total  N  N  N  N  N  N  N (%)  2009  9  9  4  1  1  1  25 (9)  2010  11  18  3  1  0  1  34 (12.2)  2011  8  11  0  1  0  0  20 (7)  2012  4  7  2  1  2  1  17 (6.1)  2013  15  25  6  8  3  1  58 (20)  2014  9  32  8  3  2  2  56 (20)  2015  12  30  8  10  6  1  67 (24)  Total N (%)  68 (24.5)  132 (47.5)  31 (11.2)  25 (9.0)  14 (5.0)  7 (2.5)  277 (100)  Year  0–6  7–12  13–24  25–36  37–48  48–60  Total  N  N  N  N  N  N  N (%)  2009  9  9  4  1  1  1  25 (9)  2010  11  18  3  1  0  1  34 (12.2)  2011  8  11  0  1  0  0  20 (7)  2012  4  7  2  1  2  1  17 (6.1)  2013  15  25  6  8  3  1  58 (20)  2014  9  32  8  3  2  2  56 (20)  2015  12  30  8  10  6  1  67 (24)  Total N (%)  68 (24.5)  132 (47.5)  31 (11.2)  25 (9.0)  14 (5.0)  7 (2.5)  277 (100)  Table 2 Age-wise trend of intussusception cases among children <5 years of age in a tertiary care hospital in North India, from 2009 to 2015 Year  0–6  7–12  13–24  25–36  37–48  48–60  Total  N  N  N  N  N  N  N (%)  2009  9  9  4  1  1  1  25 (9)  2010  11  18  3  1  0  1  34 (12.2)  2011  8  11  0  1  0  0  20 (7)  2012  4  7  2  1  2  1  17 (6.1)  2013  15  25  6  8  3  1  58 (20)  2014  9  32  8  3  2  2  56 (20)  2015  12  30  8  10  6  1  67 (24)  Total N (%)  68 (24.5)  132 (47.5)  31 (11.2)  25 (9.0)  14 (5.0)  7 (2.5)  277 (100)  Year  0–6  7–12  13–24  25–36  37–48  48–60  Total  N  N  N  N  N  N  N (%)  2009  9  9  4  1  1  1  25 (9)  2010  11  18  3  1  0  1  34 (12.2)  2011  8  11  0  1  0  0  20 (7)  2012  4  7  2  1  2  1  17 (6.1)  2013  15  25  6  8  3  1  58 (20)  2014  9  32  8  3  2  2  56 (20)  2015  12  30  8  10  6  1  67 (24)  Total N (%)  68 (24.5)  132 (47.5)  31 (11.2)  25 (9.0)  14 (5.0)  7 (2.5)  277 (100)  Overall, 22% cases presented with single, 36.4% with two, 25% with three, 27% with four, 4.3% with five, and 1.4% with six complaints (Table 3). The most common dual presentation was vomiting with abdominal pain (37.4%). The cases with history of abdominal distension (40 vs. 22.1%, p = 0.002), diarrhoea (7 vs. 1.1%, p = 0.005), vomiting (82.3 vs. 70.2%, p = 0.03), and complications (7 vs. 2.2%, p = 0.045) were significantly higher in the retrospective as compared with the prospective period. Also, there was significantly (p = 0.000) higher proportion of patients who had abdominal ultrasound done in the prospective as compared with retrospective period (100 vs. 92.7%). Age-wise clinical signs and symptoms are given in Table 4. Table 3 Clinical presentation of intussusception cases among children <5 years of age in a tertiary care hospital in North India, from 2009 to 2015 Number of complaints  Period   Complaints (number of cases)  Retrospective N (%)  Prospective N (%)  Total N (%)  One  22 (22.9)  39 (21.5)  61 (22)  Vomiting (23), abdominal pain (21), blood in stool (6), abdominal distention (6), fever (4), loose stool (1)  Two  29 (30.2)  72 (39.8)  101 (36.4)  Vomiting+abdominal pain (35), vomiting+blood in stool (21), vomiting+abdominal distention (11), vomiting+fever (5), vomiting+loose stool (4), vomiting+diarrhea (1), abdominal pain+blood in stool (11), abdominal pain+abdominal distention (3), abdominal pain+fever (3), abdominal pain+loose stool (4), blood in stool+abdominal distention (2), blood in stool+loose stool (1)  Three  33 (34.4)  36 (19.9)  70 (25.2)  Vomiting+abdominal pain+blood in stool (14), vomiting+abdominal pain+abdominal distention (5), vomiting+abdominal pain+fever (8), vomiting+abdominal pain+loose stool (1), vomiting+abdominal pain+diarrhea (2), vomiting+blood in stool+abdominal distention (10), vomiting+blood in stool+fever (4), vomiting+blood in stool+loose stool (2), vomiting+blood in stool+diarrhea (2), vomiting+abdominal distention+fever (6), vomiting+abdominal distention+loose stool (2), vomiting+abdominal distention+diarrhea (1), vomiting+abdominal distention+altered sensorium (1), vomiting+fever+loose stool (4), vomiting+fever+diarrhea (1), vomiting+fever+altered sensorium (1), abdominal pain+blood in stool+abdominal distention (2), abdominal pain+blood in stool+nausea (1), abdominal pain+abdominal distention+loose stool (1), abdominal pain+abdominal distention+diarrhea (1), abdominal pain+loose stool+blood in stool (1)  Four  8 (8.3)  20 (11.0)  27 (9.7)  Vomiting+abdominal pain+blood in stool+abdominal distention (4), vomiting+abdominal pain+blood in stool+fever (8), vomiting+abdominal pain+blood in stool+loose stool (3), vomiting+abdominal pain+blood in stool+diarrhea (1), vomiting+abdominal pain+abdominal distention+fever (6), vomiting+abdominal pain+fever+loose stool (1), vomiting+blood in stool+abdominal distention+loose stool (1), vomiting+blood in stool+fever+loose stool (1), vomiting+abdominal distention+fever+loose stool (1), abdominal pain+blood in stool+abdominal distention+fever (1)  Five  2 (2.1)  10 (5.5)  12 (4.3)  Vomiting+abdominal pain+blood in stool+abdominal distention+fever (7), vomiting+abdominal pain+blood in stool+abdominal distention+loose stool (2), vomiting+abdominal pain+blood in stool+fever+loose stool (2), vomiting+abdominal pain+abdominal distention+fever+loose stool (1)  Six  1 (1)  3 (1.7)  4 (1.4)  Vomiting+abdominal pain+blood in stool+abdominal distention+fever+loose stool (4)  None  1 (1)  1 (0.6)  2 (0.7)  –  Total cases  96 (34.6)  181 (65.3)  277 (100)    Number of complaints  Period   Complaints (number of cases)  Retrospective N (%)  Prospective N (%)  Total N (%)  One  22 (22.9)  39 (21.5)  61 (22)  Vomiting (23), abdominal pain (21), blood in stool (6), abdominal distention (6), fever (4), loose stool (1)  Two  29 (30.2)  72 (39.8)  101 (36.4)  Vomiting+abdominal pain (35), vomiting+blood in stool (21), vomiting+abdominal distention (11), vomiting+fever (5), vomiting+loose stool (4), vomiting+diarrhea (1), abdominal pain+blood in stool (11), abdominal pain+abdominal distention (3), abdominal pain+fever (3), abdominal pain+loose stool (4), blood in stool+abdominal distention (2), blood in stool+loose stool (1)  Three  33 (34.4)  36 (19.9)  70 (25.2)  Vomiting+abdominal pain+blood in stool (14), vomiting+abdominal pain+abdominal distention (5), vomiting+abdominal pain+fever (8), vomiting+abdominal pain+loose stool (1), vomiting+abdominal pain+diarrhea (2), vomiting+blood in stool+abdominal distention (10), vomiting+blood in stool+fever (4), vomiting+blood in stool+loose stool (2), vomiting+blood in stool+diarrhea (2), vomiting+abdominal distention+fever (6), vomiting+abdominal distention+loose stool (2), vomiting+abdominal distention+diarrhea (1), vomiting+abdominal distention+altered sensorium (1), vomiting+fever+loose stool (4), vomiting+fever+diarrhea (1), vomiting+fever+altered sensorium (1), abdominal pain+blood in stool+abdominal distention (2), abdominal pain+blood in stool+nausea (1), abdominal pain+abdominal distention+loose stool (1), abdominal pain+abdominal distention+diarrhea (1), abdominal pain+loose stool+blood in stool (1)  Four  8 (8.3)  20 (11.0)  27 (9.7)  Vomiting+abdominal pain+blood in stool+abdominal distention (4), vomiting+abdominal pain+blood in stool+fever (8), vomiting+abdominal pain+blood in stool+loose stool (3), vomiting+abdominal pain+blood in stool+diarrhea (1), vomiting+abdominal pain+abdominal distention+fever (6), vomiting+abdominal pain+fever+loose stool (1), vomiting+blood in stool+abdominal distention+loose stool (1), vomiting+blood in stool+fever+loose stool (1), vomiting+abdominal distention+fever+loose stool (1), abdominal pain+blood in stool+abdominal distention+fever (1)  Five  2 (2.1)  10 (5.5)  12 (4.3)  Vomiting+abdominal pain+blood in stool+abdominal distention+fever (7), vomiting+abdominal pain+blood in stool+abdominal distention+loose stool (2), vomiting+abdominal pain+blood in stool+fever+loose stool (2), vomiting+abdominal pain+abdominal distention+fever+loose stool (1)  Six  1 (1)  3 (1.7)  4 (1.4)  Vomiting+abdominal pain+blood in stool+abdominal distention+fever+loose stool (4)  None  1 (1)  1 (0.6)  2 (0.7)  –  Total cases  96 (34.6)  181 (65.3)  277 (100)    p = 0.149 Table 3 Clinical presentation of intussusception cases among children <5 years of age in a tertiary care hospital in North India, from 2009 to 2015 Number of complaints  Period   Complaints (number of cases)  Retrospective N (%)  Prospective N (%)  Total N (%)  One  22 (22.9)  39 (21.5)  61 (22)  Vomiting (23), abdominal pain (21), blood in stool (6), abdominal distention (6), fever (4), loose stool (1)  Two  29 (30.2)  72 (39.8)  101 (36.4)  Vomiting+abdominal pain (35), vomiting+blood in stool (21), vomiting+abdominal distention (11), vomiting+fever (5), vomiting+loose stool (4), vomiting+diarrhea (1), abdominal pain+blood in stool (11), abdominal pain+abdominal distention (3), abdominal pain+fever (3), abdominal pain+loose stool (4), blood in stool+abdominal distention (2), blood in stool+loose stool (1)  Three  33 (34.4)  36 (19.9)  70 (25.2)  Vomiting+abdominal pain+blood in stool (14), vomiting+abdominal pain+abdominal distention (5), vomiting+abdominal pain+fever (8), vomiting+abdominal pain+loose stool (1), vomiting+abdominal pain+diarrhea (2), vomiting+blood in stool+abdominal distention (10), vomiting+blood in stool+fever (4), vomiting+blood in stool+loose stool (2), vomiting+blood in stool+diarrhea (2), vomiting+abdominal distention+fever (6), vomiting+abdominal distention+loose stool (2), vomiting+abdominal distention+diarrhea (1), vomiting+abdominal distention+altered sensorium (1), vomiting+fever+loose stool (4), vomiting+fever+diarrhea (1), vomiting+fever+altered sensorium (1), abdominal pain+blood in stool+abdominal distention (2), abdominal pain+blood in stool+nausea (1), abdominal pain+abdominal distention+loose stool (1), abdominal pain+abdominal distention+diarrhea (1), abdominal pain+loose stool+blood in stool (1)  Four  8 (8.3)  20 (11.0)  27 (9.7)  Vomiting+abdominal pain+blood in stool+abdominal distention (4), vomiting+abdominal pain+blood in stool+fever (8), vomiting+abdominal pain+blood in stool+loose stool (3), vomiting+abdominal pain+blood in stool+diarrhea (1), vomiting+abdominal pain+abdominal distention+fever (6), vomiting+abdominal pain+fever+loose stool (1), vomiting+blood in stool+abdominal distention+loose stool (1), vomiting+blood in stool+fever+loose stool (1), vomiting+abdominal distention+fever+loose stool (1), abdominal pain+blood in stool+abdominal distention+fever (1)  Five  2 (2.1)  10 (5.5)  12 (4.3)  Vomiting+abdominal pain+blood in stool+abdominal distention+fever (7), vomiting+abdominal pain+blood in stool+abdominal distention+loose stool (2), vomiting+abdominal pain+blood in stool+fever+loose stool (2), vomiting+abdominal pain+abdominal distention+fever+loose stool (1)  Six  1 (1)  3 (1.7)  4 (1.4)  Vomiting+abdominal pain+blood in stool+abdominal distention+fever+loose stool (4)  None  1 (1)  1 (0.6)  2 (0.7)  –  Total cases  96 (34.6)  181 (65.3)  277 (100)    Number of complaints  Period   Complaints (number of cases)  Retrospective N (%)  Prospective N (%)  Total N (%)  One  22 (22.9)  39 (21.5)  61 (22)  Vomiting (23), abdominal pain (21), blood in stool (6), abdominal distention (6), fever (4), loose stool (1)  Two  29 (30.2)  72 (39.8)  101 (36.4)  Vomiting+abdominal pain (35), vomiting+blood in stool (21), vomiting+abdominal distention (11), vomiting+fever (5), vomiting+loose stool (4), vomiting+diarrhea (1), abdominal pain+blood in stool (11), abdominal pain+abdominal distention (3), abdominal pain+fever (3), abdominal pain+loose stool (4), blood in stool+abdominal distention (2), blood in stool+loose stool (1)  Three  33 (34.4)  36 (19.9)  70 (25.2)  Vomiting+abdominal pain+blood in stool (14), vomiting+abdominal pain+abdominal distention (5), vomiting+abdominal pain+fever (8), vomiting+abdominal pain+loose stool (1), vomiting+abdominal pain+diarrhea (2), vomiting+blood in stool+abdominal distention (10), vomiting+blood in stool+fever (4), vomiting+blood in stool+loose stool (2), vomiting+blood in stool+diarrhea (2), vomiting+abdominal distention+fever (6), vomiting+abdominal distention+loose stool (2), vomiting+abdominal distention+diarrhea (1), vomiting+abdominal distention+altered sensorium (1), vomiting+fever+loose stool (4), vomiting+fever+diarrhea (1), vomiting+fever+altered sensorium (1), abdominal pain+blood in stool+abdominal distention (2), abdominal pain+blood in stool+nausea (1), abdominal pain+abdominal distention+loose stool (1), abdominal pain+abdominal distention+diarrhea (1), abdominal pain+loose stool+blood in stool (1)  Four  8 (8.3)  20 (11.0)  27 (9.7)  Vomiting+abdominal pain+blood in stool+abdominal distention (4), vomiting+abdominal pain+blood in stool+fever (8), vomiting+abdominal pain+blood in stool+loose stool (3), vomiting+abdominal pain+blood in stool+diarrhea (1), vomiting+abdominal pain+abdominal distention+fever (6), vomiting+abdominal pain+fever+loose stool (1), vomiting+blood in stool+abdominal distention+loose stool (1), vomiting+blood in stool+fever+loose stool (1), vomiting+abdominal distention+fever+loose stool (1), abdominal pain+blood in stool+abdominal distention+fever (1)  Five  2 (2.1)  10 (5.5)  12 (4.3)  Vomiting+abdominal pain+blood in stool+abdominal distention+fever (7), vomiting+abdominal pain+blood in stool+abdominal distention+loose stool (2), vomiting+abdominal pain+blood in stool+fever+loose stool (2), vomiting+abdominal pain+abdominal distention+fever+loose stool (1)  Six  1 (1)  3 (1.7)  4 (1.4)  Vomiting+abdominal pain+blood in stool+abdominal distention+fever+loose stool (4)  None  1 (1)  1 (0.6)  2 (0.7)  –  Total cases  96 (34.6)  181 (65.3)  277 (100)    p = 0.149 Table 4 Age-wise signs and symptoms of intussusception cases among children <5 years of age in a tertiary care hospital in North India, during 2009–15 Age in months  Vomiting (%)  Abdominal pain (%)  Blood in stool (%)  Abdominal distention (%)  Fever (%)  Loose stool (%)  Diarrhea (%)  Altered sensorium (%)  Nausea (%)  0–12 (n=200)  79.0  46.5  45.5  32.0  24.9  14.4  4.0  0.5  0.5  13–24 (n=31)  64.5  74.2  25.8  19.4  19.4  12.9  0.0  3.2  0.0  25–36 (n=25)  56.0  72.0  20.0  20.0  24.0  12.0  4.0  0.0  0.0  37–48 (n=14)  64.3  92.9  35.7  28.6  21.4  7.1  0.0  0.0  0.0  49–60 (n=7)  71.4  71.4  28.6  0.0  42.9  14.3  0.0  0.0  0.0  Total (N=277)  74.4  54.9  40.1  28.5  24.5  13.7  3.2  0.7  0.4  Age in months  Vomiting (%)  Abdominal pain (%)  Blood in stool (%)  Abdominal distention (%)  Fever (%)  Loose stool (%)  Diarrhea (%)  Altered sensorium (%)  Nausea (%)  0–12 (n=200)  79.0  46.5  45.5  32.0  24.9  14.4  4.0  0.5  0.5  13–24 (n=31)  64.5  74.2  25.8  19.4  19.4  12.9  0.0  3.2  0.0  25–36 (n=25)  56.0  72.0  20.0  20.0  24.0  12.0  4.0  0.0  0.0  37–48 (n=14)  64.3  92.9  35.7  28.6  21.4  7.1  0.0  0.0  0.0  49–60 (n=7)  71.4  71.4  28.6  0.0  42.9  14.3  0.0  0.0  0.0  Total (N=277)  74.4  54.9  40.1  28.5  24.5  13.7  3.2  0.7  0.4  Table 4 Age-wise signs and symptoms of intussusception cases among children <5 years of age in a tertiary care hospital in North India, during 2009–15 Age in months  Vomiting (%)  Abdominal pain (%)  Blood in stool (%)  Abdominal distention (%)  Fever (%)  Loose stool (%)  Diarrhea (%)  Altered sensorium (%)  Nausea (%)  0–12 (n=200)  79.0  46.5  45.5  32.0  24.9  14.4  4.0  0.5  0.5  13–24 (n=31)  64.5  74.2  25.8  19.4  19.4  12.9  0.0  3.2  0.0  25–36 (n=25)  56.0  72.0  20.0  20.0  24.0  12.0  4.0  0.0  0.0  37–48 (n=14)  64.3  92.9  35.7  28.6  21.4  7.1  0.0  0.0  0.0  49–60 (n=7)  71.4  71.4  28.6  0.0  42.9  14.3  0.0  0.0  0.0  Total (N=277)  74.4  54.9  40.1  28.5  24.5  13.7  3.2  0.7  0.4  Age in months  Vomiting (%)  Abdominal pain (%)  Blood in stool (%)  Abdominal distention (%)  Fever (%)  Loose stool (%)  Diarrhea (%)  Altered sensorium (%)  Nausea (%)  0–12 (n=200)  79.0  46.5  45.5  32.0  24.9  14.4  4.0  0.5  0.5  13–24 (n=31)  64.5  74.2  25.8  19.4  19.4  12.9  0.0  3.2  0.0  25–36 (n=25)  56.0  72.0  20.0  20.0  24.0  12.0  4.0  0.0  0.0  37–48 (n=14)  64.3  92.9  35.7  28.6  21.4  7.1  0.0  0.0  0.0  49–60 (n=7)  71.4  71.4  28.6  0.0  42.9  14.3  0.0  0.0  0.0  Total (N=277)  74.4  54.9  40.1  28.5  24.5  13.7  3.2  0.7  0.4  Nearly 61.7% of the patients required surgical intervention, and 33% cases were resolved by the non-surgical interventions. Among those who required a non-surgical intervention, pneumatic reduction was possible in 75 (27%), conservative management in 14 (5%), barium reduction in 2 (0.7%) cases and laparoscopic reduction was done in 1 case (0.3%). In 14 (5%) cases, treatment procedure was not specified. There was no death reported because of intussusception. Average duration of stay in the hospital was 6 days. The most common location of intussusception was ileocolic region (77%), followed by ileoileal (7.9%), colocolic (4.7%), ileo-ileocolic (2.2%), and jejunojejunal (1.8%). Most of the intussusceptions were single (97.8%). The location of the intussusception in the patients who had non-surgical interventions (n = 91) was recorded from the ultrasound reports. There were six (2.1%) cases of secondary intussusception (two Meckel’s diverticulum, two ileal polyps, one malrotation of gut and one mesenteric cyst), and rest were idiopathic (98%). Incidence of intussusception in Chandigarh was estimated to be 20 cases per 100 000 infants per year (range 10–33/100 000 infants), and 5/100 000 children <5 years of age per year (range 4–7/100 000 under-five-children) (Supplementary Table 1). DISCUSSION The results of this study provided background estimates of hospital admission and incidence rate of intussusception among children <5 years of age in North India. These results are useful for the policymakers and programme implementers for comparison purposes following the introduction of rotavirus vaccination in national immunization schedule in India. Average number of intussusception cases (24 cases) reported in the retrospective period in this study is similar to a retrospective hospital-based study by Singh et al. [11] in Manipal (20 cases) and Lucknow (14 cases) in India. However, lack of incidence data in the Singh et al. [11] study prevented the comparison of the incidence rate with this study. The reasons for increase in intussusception rate (60/year vs. 24/year) during prospective (2013–15) as compared with the retrospective period (2009–12) could be the active mode of prospective surveillance, increased use of diagnostics (abdominal ultrasonography) or higher referral of intussusception cases during prospective surveillance. Prospective surveillance is considered to be a better method of surveillance for intussusception because of its completeness [12]. Hence, we have based the estimation of incidence of intussusception cases in Chandigarh on the data obtained in this period, and limited the discussion for this period only. Incidence of intussusception among infants as estimated in this study in Chandigarh (20 cases per 100 000 infant-years) is similar to that reported in Delhi (17.7 cases per 100 000 infant-years) by Bahl et al. [13] among infants. This may be because of the similar geographical area and prevalence of causative organisms for diarrhoea or infant-feeding practices in these two North Indian cities. Previous studies (2001–07) in developed countries have reported incidence rates of intussusception ranging from 30 to 130 cases per 100 000 infant-years [14–21]. Higher rates of intussusception in developed countries as compared with this study could be because of better study design (like cohort study) and better tracking and reporting of intussusception cases. In Vietnam, higher incidence of 302 cases per 100 000 infant-years was associated with adenovirus infection [22]. Summary of worldwide age-wise incidence of intussusception reported in the past 5 years, in the pre-rotavirus vaccination period, is given in Supplementary Table 2 [23–35]. The age at which maximum numbers of cases were recorded in this study was between 7 and 12 months, which is similar to other studies in India [11, 32] and abroad [29, 31]. The age-wise distribution of intussusception cases in this study (Table 1) is similar to Mandeville et al. [36] study. The increase in the median age of diagnosis from 7 months during the retrospective period to 12 months during the prospective period in this study is in line with the previous studies in developed countries [29, 37, 38]. The probable reason for the age shift has been related to delayed or reduced exposure to childhood infections arising from improving standards of hygiene and sanitation in these countries. However, we need high-quality long-term local surveillance to explore reasons for the same in developing nations. Similar male to female ratio (3:1) as observed in this study is also reported in previous studies in India [11, 39]. Although the ratio varies widely across different countries, there is predominance of males in previous studies also. The ratio varies from 1.3:1 in Singapore [19] to 9:1 in India [11, 40, 41]. Predominance of males in Indian settings could be because of sex-linked preferential treatment given to the sons as compared with the daughters [42, 43]. Seasonal variation in the intussusception cases is similar to other studies done in India [11] and abroad [19, 44, 45]. This trend also corresponds with the seasonality seen with acute diarrheal diseases, especially, in North India [46, 47]. However, no seasonal variation in the intussusception cases was reported in South India [39], and in Tanzania [44] and Latin America [27] abroad because of the different climatic conditions prevalent in different parts of India and abroad. Proportion of secondary intussusception cases (2%) among children <5 years of age as observed in this study is consistent with existing literature [48–51]. The clinical signs and symptoms of intussusception as reported in this study were similar to those reported previously in other studies [11, 32, 36, 39]. Similar differences in the clinical presentation in the retrospective and prospective period were also observed in a South Indian study [52]. This could be because of late presentation and management of cases in the retrospective as compared with prospective period. Most of the cases of intussusception were managed by surgical intervention as is also reported from other hospital-based surveillance study in India [11, 32]. However, surgical intervention was required in lower proportion of cases in this study (61.7%) as compared with previous study (71%) [11]. This could be because of more experience and advancement in technology to reduce intussusception by non-surgical methods [53]. The strength of this study is the use of standard case definition, reliable documentation and prospective surveillance design of intussusception cases. The cases of intussusception were ascertained by qualified, experienced and dedicated team of paediatric surgeon and radiologist, thereby ruling out error of miss-classification. Reporting of intussusception cases from paediatric surgery wards and emergency in addition to case record department had increased the chances of complete data capturing. This study strengthened the evidence on setting up of prospective intussusception surveillance in the country [52]. However, there are certain limitations in the study, such as history of rotavirus immunization was not obtained, as that was not the primary objective of the study, and also because rotavirus vaccine was not introduced in the universal immunization program during the study period (2009–15). As this was a hospital-based surveillance in a North Indian tertiary care hospital with no defined catchment area, estimation of state-specific incidence of cases of intussusception is not done, except for UT Chandigarh as this hospital was located in Chandigarh itself. However, the estimated incidence of intussusception in Chandigarh might also be an underestimation, as the cases that might have been treated in the private health facilities were missed. Future research may be planned to conduct longitudinal hospital-cum-community-based studies so as to have reliable estimates on the incidence and aetiology of intussusception, and also on the management of intussusception in the peripheral hospitals. SUPPLEMENTARY DATA Supplementary data are available at Journal of Tropical Pediatrics online. ACKNOWLEDGEMENTS The authors are thankful to resident doctors and nurses of Advanced Pediatric Center, and Department of Community Medicine, PGIMER, Chandigarh for data collection. 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Journal

Journal of Tropical PediatricsOxford University Press

Published: Oct 11, 2017

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