RESEARCH

Global Illness and Deaths Caused

by Rotavirus Disease in Children
Umesh D. Parashar,* Erik G. Hummelman,*Joseph S. Bresee,* Mark A. Miller, and Roger I. Glass*

To estimate the global illness and deaths caused by

rotavirus disease, we reviewed studies published from
1986 to 2000 on deaths caused by diarrhea and on
rotavirus infections in children. We assessed rotavirusassociated illness in three clinical settings (mild cases
requiring home care alone, moderate cases requiring a
clinic visit, and severe cases requiring hospitalization) and
death rates in countries in different World Bank income
groups. Each year, rotavirus causes approximately 111 million episodes of gastroenteritis requiring only home care,
25 million clinic visits, 2 million hospitalizations, and
352,000592,000 deaths (median, 440,000 deaths) in children <5 years of age. By age 5, nearly every child will have
an episode of rotavirus gastroenteritis, 1 in 5 will visit a
clinic, 1 in 65 will be hospitalized, and approximately 1 in
293 will die. Children in the poorest countries account for
82% of rotavirus deaths. The tremendous incidence of
rotavirus disease underscores the urgent need for interventions, such as vaccines, particularly to prevent childhood
deaths in developing nations.

n 1985, de Zoysa and Feachem published their landmark

review of the global prevalence of rotavirus disease (1).
Their analyses indicated that rotavirus accounted for 6% of
diarrhea episodes and 20% of deaths caused by diarrhea in
children <5 years of age in developing countries. The incidence of rotavirus disease was observed to be similar in
both industrialized and developing countries, suggesting
that adequate control may not be achieved by improvements in water supply, hygiene, and sanitation.
Consequently, the development, trial, and widespread use
of rotavirus vaccines were recommended to prevent severe
and fatal rotavirus disease.
Since then, rapid progress has been made in developing
and testing several rotavirus vaccine candidates (2,3). In
August 1998, a live, attenuated rotavirus vaccine
(Rotashield, Wyeth Laboratories, Marietta, PA) was
licensed in the United States and recommended for routine
immunization of U.S. infants. However, 9 months later, the
use of Rotashield was suspended because reports suggested a possible association with intussusception (4). After
this association was confirmed, the recommendation for
*Centers for Disease Control and Prevention, Atlanta, Georgia,
USA; and Fogarty International Center, National Institutes of
Health, Bethesda, Maryland, USA

use of Rotashield was withdrawn and the manufacturer

stopped vaccine production.
Efforts are ongoing to develop other rotavirus vaccines,
and several candidates are undergoing clinical testing (3).
In addition to their safety and efficacy, the decision to
implement these new rotavirus vaccines will be based on
considerations of risk-benefit and cost-effectiveness.
Updated estimates of rotavirus disease prevalence are a
prerequisite to formulating such policy and carrying out
economic analyses as well as advocacy for the next generation of rotavirus vaccines. Furthermore, each country that
considers using a rotavirus vaccine may want to review the
prevalence of rotavirus disease in their setting.
Since 1985, deaths from diarrheal diseases in children
have declined substantially around the world, and a recent
analysis suggested that deaths from rotavirus infections
might also have been reduced during this period (5,6).
Furthermore, scant information is available on the global
extent of illness from rotavirus disease, particularly hospitalizations, which constitute a major component of total
rotavirus health costs in industrialized nations. To provide
updated estimates of the global illness and death from
rotavirus disease in children, we reviewed studies of childhood deaths from diarrhea and of rotavirus infections published from 1986 to 2000. We also present preliminary
estimates of country-specific mortality rates from rotavirus
disease as targets for further study and refinement through
local definition of problems. These findings should help
policy makers assess the magnitude of the problem of
rotavirus disease in their own countries and set priorities
for interventions to prevent this disease.
Methods
Selection of Studies

The studies selected for this analysis were identified

from a computer search of the scientific literature published in English between 1986 and 2000. To find studies
of childhood deaths from diarrhea, we conducted a search
using the keywords childhood mortality, deaths, and
diarrhea. We added references by reviewing the citations
in these articles and by consulting with experts in the field.
Because most studies of diarrhea deaths were conducted in
countries with a low-income population, we supplemented

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these studies with published reports of vital registration

data to analyze child death patterns in selected countries
with middle- and high-income populations.
To identify studies of rotavirus disease, we conducted a
search using the keyword rotavirus and cross-linked the
articles with a second set of articles obtained from a secondary search using these keywords: incidence, prevalence,
public health, death rate, mortality, surveillance, burden,
suffering, distribution, area, location, and country. We also
searched for permutations of these root words: epidemiol,
monitor, and geograph. We then reviewed the resulting
linked set of articles and narrowed it down to articles with
content that was relevant to the goals of this study. We identified additional citations from references in these articles.
Studies of rotavirus were included if they continued for at
least 1 year, contained data on children <5 years of age, and
reported using an enzyme immunoassay (EIA) or similar
reliable assay to detect rotavirus. A listing of the studies
included in the analyses is available in Appendix A (online
only; available from: URL: http://www.cdc.gov/ncidod/
EID/vol9no5/02-0562.appA.htm).
Analysis of Data
Rotavirus-Associated Illness

To estimate the extent of illness from rotavirus in children in developing countries, we first multiplied the total
population of infants (011 months) and children (1259
months) in those countries by the estimated annual incidence of diarrhea in the respective age groups (5,7). On the
basis of published estimates from a study in Chile (8), we
then distributed these diarrhea episodes into three settings:
mild cases only requiring care at home; moderate cases
requiring care in an outpatient clinic; and severe cases
requiring hospitalization. Next, on the basis of studies we
reviewed, we calculated the median proportion of diarrhea
episodes attributable to rotavirus in each of the three settings. Finally, we multiplied the total number of diarrhea
episodes in each setting by the estimated proportion attributable to rotavirus to yield the number of rotavirus cases in
each setting.
To estimate the number of hospitalizations for rotavirus
among children in industrialized countries, we multiplied
estimates of the total population of children <5 years of age
with rotavirus-associated hospitalization rates derived from
published studies. To calculate clinic visits and episodes of
rotavirus disease, we evaluated studies documenting the
frequency of these outcomes relative to hospitalizations
and multiplied the calculated total number of rotavirusassociated hospitalizations by corresponding factors. The
figures thus obtained were combined with estimates of
rotavirus illness in children in developing countries to yield
the global extent of illness from rotavirus disease.
566

Rotavirus-Associated Deaths

To estimate the total number of child deaths from diarrhea, we plotted (for each country with available data) the
fraction of deaths of children <5 years of age attributable
to diarrhea against per capita gross national product
(GNP). Countries were classified on the basis of GNP per
capita into World Bank Income Groups (low [<U.S.$756],
low-middle [U.S.$756$2,995], high-middle [U.S.
$2,996$9,265], high [>U.S. $9,265]) (9). For each
income group, we calculated the median proportion of
deaths of children <5 years of age attributable to diarrhea.
We then multiplied the median proportion for each
income group by the total number of deaths of children <5
years of age for each country in that income group to yield
country-specific estimates of the mortality rate from diarrhea. These country-specific estimates were added to calculate the global mortality rate from diarrhea.
To estimate the fraction of diarrhea deaths attributable
to rotavirus, we plotted the proportion of rotavirus infection detected in children hospitalized for diarrhea that was,
by virtue of the need for hospitalization, presumed to be
severe. These figures were again plotted against per capita
GNP for each country to yield median rotavirus detection
rates for countries in the four World Bank income groups.
Previously estimated diarrhea mortality rates for each
country in an income group was multiplied by the median
rotavirus detection rate for that income group to yield the
estimated number of rotavirus deaths by country. These
figures were added to yield the number of global deaths
from rotavirus diarrhea. For each income strata and overall, the risk of death from rotavirus diarrhea by 5 years of
age was calculated by dividing the total number of live
births by the total number of deaths from rotavirus.
Results
Rotavirus Disease in Children in Developing
Countries
Total Number of Diarrhea Episodes

An estimated 125 million infants 011 months of age

and 450 million children 14 years of age reside in developing countries. A recent review of 27 prospective studies
from 20 countries published from 1990 to 2000 estimated
the incidence of diarrhea as 3.8 episodes per child per year
for children <11 months of age and 2.1 episodes per child
per year for children 14 years of age (5). Multiplying
these age-specific incidence data with the population of
children in each age group yielded an overall estimate of
approximately 1.4 billion diarrhea episodes per year in
children <5 years of age (Table 1). Of these, 475 million
episodes are estimated to occur in <11-month-old infants
and 945 million episodes in children 14 years of age.

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Distribution of Diarrhea Episodes by Setting

A study from Chile demonstrated that in <11-month-old

infants, 88.2% of diarrhea episodes required only care at
home, 10.3% required a clinic visit, and 1.5% required
hospitalization (8). In 1- to 4-year-old children, 91.9% of
diarrhea episodes required only care at home, 7.9%
required a clinic visit, and only 0.2% required hospitalization. The proportion of all diarrhea episodes requiring hospitalization was similar in another study from Thailand
(10). Therefore, we applied the estimates from the Chilean
study to the previously calculated total number of diarrhea
episodes in each age group and distributed them into
episodes requiring only home care, clinic visit, or hospitalization (Table 1). Of the total of approximately 1.4 billion
diarrhea episodes in children <5 years of age, we estimated that 1.29 billion require home care only, 124 million
require a clinic visit, and 9 million require hospitalization.
Number of Rotavirus Episodes in Each Setting

To estimate the number of diarrhea cases in each setting

that are attributable to rotavirus, we applied proportions
calculated from studies of rotavirus in children in developing countries. The review of 24 community-based studies,
13 clinic-based studies, and 72 hospital-based studies indicated that rotavirus accounted for a median of 8.1%,
18.8%, and 21.3% of diarrhea episodes in the three settings, respectively (Table 2). By multiplying these settingspecific proportions with the total number of diarrhea
episodes in each setting, we calculated that rotavirus annually causes approximately 104 million episodes of diarrhea
requiring home care, 23 million clinic visits, and 1.9 million hospitalizations.
Illness from Rotavirus Disease in Children in
Industrialized Countries

3). By multiplying these incidence estimates with the total

population of 50,016,000 children <5 years of age in
industrialized nations, we estimated that a total of 223,000
(range 142,000358,000) rotavirus-associated hospitalizations occur in children in industrialized nations.
Clinic Visits

No reliable estimates of rotavirus-associated clinic visit

rates are available for children in industrialized countries.
However, studies have shown that for each child hospitalized with rotavirus diarrhea, approximately 510 children
require a visit to a healthcare facility or physicians office
(17,21,22). Therefore, we multiplied the estimated
223,000 rotavirus hospitalizations by a factor of 8 (range
510) to obtain an estimated total of approximately
1,781,000 (range 708,0003,576,000) clinic visits for
rotavirus disease in children <5 years of age.
Episodes Requiring Only Home Care

Studies have estimated that for each child requiring

medical attention for rotavirus disease, an additional three
to five children develop symptomatic disease requiring
only home-care (21,22). Therefore, we multiplied the estimated 1,781,000 clinic visits by a factor of 4 (range 35)
to estimate a total number of 7,122,000 (range
2,123,00017,881,000) episodes of rotavirus gastroenteritis requiring only home care in children <5 years of age.
Overall Illness from Rotavirus
Gastroenteritis Worldwide

By adding the total prevalence of rotavirus illness in

children in developing and industrialized nations, we estimated that each year rotavirus causes approximately 111
million episodes of gastroenteritis that require home care
only, 25 million clinic visits, and 2 million hospitalizations
in children <5 years of age worldwide (Table 4).

Hospitalizations

Examination of rotavirus-specific annual hospitalization incidence from several industrialized countries

demonstrated a median rate of 445 per 100,000 children
(interquartile range, 283715 per 100,000) (1120) (Table

Deaths from Rotavirus Disease in Children

<5 Years of Age Worldwide

The proportion of deaths in children <5 years of age

attributable to diarrhea demonstrated a declining trend

Table 1. Estimates of the annual number of diarrhea episodes among children <5 years of age in developing countries, by age group
and settinga
Age group
<11 mo
14 y
Total (<4 y)
Total population (x1,000)
125,000
450,000
575,000
No. of diarrhea episodes per child per yb
3.8
2.1
NA
Total diarrhea episodes (x1,000)
475,000
945,000
1,420,000
No. of episodes at home (x1,000)
418,950 (88.2)
868,455 (91.9)
1,287,405
No. of episodes in outpatients (x1,000)
48,925 (10.3)
74,655 (7.9)
123,580
No. of case-patients hospitalized (x1,000)
7,125 (1.5)
1,890 (0.2)
9,015
a

Figures in parenthesis are percentages of total diarrhea episodes (7).

From reference (5).

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Table 2. Estimates of the annual number of episodes of rotavirus diarrhea among children <5 years of age in developing countries, by
setting
Home
Outpatient
Inpatient
Annual no. of diarrhea episodes (x1,000)
1,287,405
123,580
9,015
Median % of episodes with rotavirus (IQR)a
8.1 (4.012.2)
18.8 (15.022.0)
21.3 (17.228.8)
Total rotavirus episodes (range) (x1,000)
104,280 (51,496157,063)
23,233 (18,53727,188)
1,920 (1,5512,596)
a

IQR, interquartile range.

with increasing income level (Figure 1A); the median proportion for low-income countries was 21%; for low-middle income countries, 17%; for high-middle income countries, 9%; and for high-income countries, 1%. We multiplied these income stratum-specific median estimates with
the combined <5 mortality estimates for countries in each
of the four income strata to yield an overall estimate of 2.1
million (range 1.7 million3.0 million) diarrhea deaths per
year (Table 5). Of the median 2.1 million diarrhea deaths,
85% (N=1,805,000) occurred in children from low-income
countries.
The proportion of diarrhea hospitalizations attributable
to rotavirus demonstrated an increasing trend with increasing income level (Figure 1B); the median for low-income
countries was 20%; for low-middle income countries,
25%; for high-middle income countries, 31%; and for
high-income countries, 34%. We multiplied these stratumspecific proportions with the median estimate of total diarrhea deaths for countries in each of the four income strata
to yield an estimated 352,000592,000 (median 440,000
deaths) per year from rotavirus. Of the median 440,000
deaths, 82% (N=361,000) occurred in children from lowincome countries.
To obtain country-specific estimates of deaths from
diarrhea and rotavirus disease, we first multiplied United
Nations Childrens Fund estimates of total number of

deaths of children <5 years of age for each country in each

income stratum with the median proportion for that stratum of deaths in children <5 years of age attributable to
diarrhea. The obtained country-specific estimates of diarrhea deaths were further multiplied by the median proportion for that stratum of diarrhea hospitalizations attributable to rotavirus. The results of these calculations are presented in the Appendix B (online only; available from:
URL: http://www.cdc.gov/ncidod/EID/vol9no5/02-0562_
appB.htm) and shown in Figure 2.
Discussion
The findings of this study demonstrate the tremendous
amount of global illness and deaths caused by rotavirus
disease. Each year, rotavirus causes an estimated 111 million episodes of diarrhea requiring only home care, 25 million clinic visits, 2 million hospitalizations, and
352,000592,000 deaths (median 440,000 deaths) in children <5 years of age. In other words, by 5 years of age,
almost all children will have an episode of rotavirus gastroenteritis, 1 in 5 will require a clinic visit, 1 in 65 will
require hospitalization, and approximately 1 in 293 will
die (Figure 3). The incidence of rotavirus disease is similar in children in both developed and developing nations.
However, children in developing nations die more frequently, possibly because of several factors, including

Table 3. Annual incidence of hospitalizations for rotavirus gastroenteritis in children <5 years of age in selected industrialized countries
Country (reference)
Y
Annual incidence/100,000 children
Cumulative incidence by 5 y of age
Spain (11)
19891995
250
1 in 80
Netherlands (12)
1998
270
1 in 74
United States (13)
19931995
274
1 in 73
Poland (14)
1996
310
1 in 65
Sweden (15)
19931996
370a
1 in 54
United Kingdom (16)
19931994
520
1 in 38
Finland (17)
19851995
610
1 in 33
Australia (18)
19931996
750
1 in 27
Hungary (19)
19931996
840a
1 in 24
Australia (20)
19911993
870
1 in 23
a

Incidence for children <4 years of age.

Table 4. Annual global illness incidence from rotavirus disease among children <5 years age, by setting
No. (range) of episodes of rotavirus disease (x1,000)
Setting
Developing countries
Industrialized countries
Total
Home
104,280 (51,496157,063)
7,122 (2,12317,881)
111,402 (53,619174,946)
Outpatient
23,233 (18,53727,188)
1,781 (7083,576)
25,017 (19,24530,764)
Inpatient
1,920 (1,5512,596)
223 (142358)
2,143 (1,6932,954)

568

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Figure 1. A. Percentage of deaths in children <5 years that are attributable to diarrhea for countries in different World Bank income
groups, by gross national product (GNP) per capita of the country. B. Percentage of diarrhea hospitalization attributable to rotavirus for
countries in different World Bank income groups, by GNP per capita of the country. IQR, interquartile range.

poorer access to hydration therapy and a greater prevalence of malnutrition. An estimated 1,205 children die
from rotavirus disease each day, and 82% of these deaths
occur in children in the poorest countries.
In 1986, the Institute of Medicine (IOM) estimated, on
the basis of published studies and field experience, that
annually rotavirus causes approximately 110 million
episodes of mild diarrhea, 10 million episodes of moderate
to severe diarrhea, and 9 million episodes of severe diarrhea in children <5 years of age worldwide (23). Our estimate of the incidence of rotavirus gastroenteritis is similar
to the IOM estimate and is consistent with a recent analysis demonstrating that overall diarrhea illness in children
worldwide has not declined appreciably in the past two
decades (5). However, our estimate of total hospitalizations from rotavirus disease is substantially lower than the
IOM estimate. The difference might be explained, in part,
by the relatively low hospitalization rate for diarrhea in the
study in Chile (1.5% of all diarrhea episodes) used in our
calculations (8). However, a study in a low-income urban
community in Thailand showed a similar hospitalization
rate (1% of all diarrhea episodes) among children with
diarrhea (10), giving us added confidence in our estimates.

Increased use of oral rehydration therapy and improvements in nutritional status are two factors that might
explain a possible reduction in severe rotavirus cases without a concomitant decline in diarrhea incidence (24,25).
Our estimate of 352,000592,000 deaths (median:
440,000 deaths) from rotavirus disease each year is similar
to a recent estimate of 418,000520,000 deaths proposed
by Miller and McCann (6) but is substantially lower than
the 1985 IOM estimate of 873,000 deaths. This decline in
the rotavirus mortality rate parallels the decline in overall
deaths from diarrhea in children in the past two decades,
from an estimated 4.6 million deaths in 1982 (26) to our
estimate of 2.1 million deaths in 2000. However, the patterns of diarrhea deaths reported in this study reflect the
situation a decade ago, when most studies that we
reviewed were conducted. Analyses of vital registration
data from several countries have suggested that the proportion of deaths from diarrhea may have declined further in
recent years (27). Other studies have noted marked discrepancies in the analysis of cause of death from vital registration data and prospective observational studies (28).
Careful and detailed analyses are required to assess the
current magnitude of the deaths from diarrhea in children,

Table 5. Global estimates of the annual number of diarrhea and rotavirus deaths among children <5 years of age, by income group
Total no. (x1,000)
Diarrhea deaths
Rotavirus deathsb
a
Income
Median % (IQR ) Median no. (IQR) of
Median % (IQR) of
Median no. (IQR) of Risk of dying from
group
rotavirus by age 5
of total deaths
deaths (x1,000)
diarrhea hospitalizations
deaths (x1,000)
Births
Deaths
Low
Low middle
Upper
middle
High
Total

70,447
37,402
11,520

8,595
1,609
366

21 (1730)
17 (1123)
9 (517)

1,805 (1,4612,579)
274 (177370)
33 (1862)

20 (1627)
25 (2033)
31 (2542)

361 (289487)
69 (5590)
10 (814)

1 in 205
1 in 542
1 in 1,152

9,931
129,300

60
10,630

1
NA

<1
2,112 (1,6573,012)

34 (2838)
NA

<1
440 (352592)

1 in 48,680
1 in 293

IQR, interquartile range; NA, not applicable.

The estimated number and range of deaths from rotavirus are derived by multiplying the median and IQR of diarrhea hospitalizations attributable to rotavirus by the
median number of deaths caused by diarrhea for each stratum
b

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Figure 2. Estimated global distribution of 440,000 annual deaths in

children caused by rotavirus diarrhea. One dot=1,000 deaths

and the results will directly affect our estimates of deaths

from rotavirus disease. For example, if our estimated proportion of severe diarrhea cases attributable to rotavirus is
applied to the recent estimate of 2.5 million annual diarrhea deaths developed by Kosek et al. (5), we estimate
416,000700,000 annual deaths (median:520,000 deaths)
from rotavirus disease.
Another important factor that could affect our estimate
of rotavirus deaths is the possibility that as the overall mortality rate from diarrhea has declined over the past two
decades, the proportion of diarrhea deaths attributable to
rotavirus may have increased, given that this pathogen is
often transmitted from person to person and is difficult to
control through improvements in hygiene and sanitation.
This hypothesis is supported by data from Mexico, demonstrating that whereas deaths from diarrhea declined substantially from 1989 to 1995, the decline was less evident
for winter seasonal deaths in children <2 years of age
whose illness met the epidemiologic features of rotavirus
diarrhea (29). In addition, some recent studies of rotavirus
based on hospital surveillance in developing countries
have demonstrated detection rates in excess of 50%
(30,31). If this trend is confirmed as additional data
become available from ongoing surveillance studies in
several regions of the world, the estimates of rotavirus
deaths reported in this article will have to be revised to
reflect current mortality patterns.
This review, based on a compilation of studies varying
in design, time, and place, has several inherent limitations
that we attempted to address. Because of the marked seasonality of rotavirus disease and the variation in the sensitivity and specificity of diagnostic tests for rotavirus, we
restricted this review to studies that lasted at least 1 year
and used reliable assays for the detection of rotavirus. To
account for known temporal changes in the magnitude and
patterns of diarrhea-associated childhood deaths, we
reviewed only studies published within the last 15 years
and used the most recent available estimates of total deaths
570

in children <5 years to calculate estimates of diarrhea

deaths. Furthermore, because regional boundaries are primarily based on geographic and political considerations
and do not necessarily reflect important determinants of
health, we used indicators of socioeconomic status to stratify our analyses of mortality patterns.
Nevertheless, we could not adequately account for several factors that may have affected our findings. First, the
studies we reviewed were conducted in selective populations that may not have been representative of the entire
country. Second, most diarrhea mortality studies used verbal autopsies to determine the cause of death, which may
affect our estimates because these methods have variable
sensitivity and specificity and it is difficult, if not impossible, to assign a single cause of death for children who died
with multiple conditions (3234). Finally, because of a
time lag between the conduct of studies and publication of
their findings, our data likely do not reflect the most current trends of diarrhea and rotavirus disease patterns.
In 1998, the first rotavirus vaccine was licensed in the
United States, offering an encouraging opportunity for the
prevention of this disease. However, the vaccine was withdrawn within a year of licensure because it caused an estimated one case of intussusception for every 12,000 vaccinated infants. The lack of sufficient data on the efficacy of
vaccine in developing countries as well as political and
ethical considerations diminished prospects for its use in
these settings. Our findings demonstrate that the next generation of rotavirus vaccines will have greatest impact in
developing countries where the disease burden is greatest.
Our estimates of rotavirus mortality rates for individual
countries, although developed with relatively crude methods, compare favorably with those from more detailed
analysis conducted in selected countries. For example,
good concordance was noted between the previous figures
and our estimates of rotavirus mortality for Bangladesh
(14,85027,000 vs. 13,104 deaths) (35), Peru (1,600 vs.
1,360 deaths) (36), and India (98,000 vs. 100,800 deaths)
(37). The establishment of regional networks for rotavirus
surveillance in sentinel hospitals will facilitate more time-

Figure 3. Estimated global prevalence of rotavirus disease.

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ly and refined estimates of disease illness and death. These

data, along with information on illness and costs of
rotavirus infections, will assist policy makers in assessing
the magnitude of the problem of rotavirus in their own setting and in setting priorities for interventions, such as the
next generation of rotavirus vaccines, which may be available in the near future.
Dr. Parashar is a medical epidemiologist with the
Respiratory and Enteric Viruses Branch, Division of Viral and
Rickettsial Diseases, National Center for Infectious Diseases,
Centers for Disease Control and Prevention. His research focuses
on the epidemiology of viral gastroenteritis and methods for its
prevention and control.
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Address for correspondence: Umesh D. Parashar, Viral Gastroenteritis
Section, Division of Viral and Rickettsial Diseases, National Center for
Infectious Diseases, Centers for Disease Control and Prevention, 1600
Clifton Road NE, Mailstop G04, Atlanta, GA 30333, USA; fax: 404-6393645; email: uap2@cdc.gov

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