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19 January 2026

8 Pages

Comparative Analysis of Direct Hospital Costs for Community Acquired Viral Gastroenteritis in Children Under 60 Months in Brasov, Romania

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1
Children’s Clinical Hospital Brasov, 500063 Brasov, Romania
2
Faculty of Medicine Brasov, Transilvania University, 500019 Brasov, Romania
3
Faculty of Mathematics, Transilvania University, 500091 Brasov, Romania
*
Author to whom correspondence should be addressed.
Germs2026, 16(1), 3;https://doi.org/10.3390/germs16010003
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Abstract

Background/Objectives: Viral gastroenteritis leads to a broad range of hospitalization costs globally in children, depending on the region. To our knowledge, no recent studies have examined the hospitalization cost associated with viral gastroenteritis in Romania. The aim of this study is to determine the direct hospitalization cost of community-acquired viral gastroenteritis (rotavirus, adenovirus and norovirus) in children admitted to Children’s Clinical Hospital of Brașov, Romania, for one year. Methods: All children aged 0–60 months hospitalized for a stool sample positive for rotavirus, adenovirus or norovirus during January 2023 and December 2023 were included in this study. Hospital-acquired gastroenteritis, gastrointestinal coinfections or children with acute coinfection were excluded. The stool specimens were tested using the immunochromatography method. Results: Out of the total of 282 children, 218 children presented rotavirus gastroenteritis, 35 children presented adenovirus gastroenteritis and 29 children presented norovirus gastroenteritis. Regarding patient characteristics, a higher proportion of boys than girls was observed in all three comparison groups, the average age for children with rotavirus was 22.2 months vs. norovirus and adenovirus, and children presented an average age of 16.4 months. Average hospitalization length of stay for rotavirus was 4.64 (±1.95) days, for adenovirus it was 4.54 (±1.52) days and for norovirus it was 4.75 (±1.93) days. Direct hospitalization costs did not differ between rotavirus, adenovirus, and norovirus infections (Kruskal–Wallis H(2) = 0.145, p = 0.930). Conclusions: In this single-center study, rotavirus remained the most frequent cause of viral gastroenteritis requiring hospitalization in young children, followed by adenovirus and norovirus. Although the average length of stay was similar across groups, hospitalization costs varied, with rotavirus-associated cases showing the highest mean expenses and widest cost variability.

1. Introduction

Acquired viral gastroenteritis is an acute infection of the gastrointestinal tract caused by viral pathogens and is most transmitted via the fecal–oral route, through contaminated food or water, or by close contact with infected individuals [1]. It typically presents with sudden-onset non-bloody, non-mucoid diarrhea, frequently accompanied by nausea, vomiting, abdominal cramping, and occasionally low-grade fever [2]. The disease is generally self-limiting and resolves within a few days [3]. Viral gastroenteritis affects all age groups; however, children under five years of age represent the most vulnerable population due to immature immune systems, higher risk of dehydration, and increased likelihood of hospitalization [2]. Among viral etiologies, rotavirus is the most common cause of gastroenteritis in children under 60 months of age, and its high frequency has led multiple studies to demonstrate that vaccination is essential for reducing the associated morbidity and mortality of the disease in this age group [4].
The direct hospitalization costs for pediatric viral gastroenteritis have a wide range by region worldwide. In Western and Southern Europe, the costs are higher compared to Central Europe. One study from Spain showed that between 2013 and 2018 the mean cost per rotavirus gastroenteritis hospitalization ranged from EUR 3940 to EUR 4100 [5]. The REVEAL study evaluated the burden of community-acquired rotavirus gastroenteritis in seven European countries and found that the total cost per hospitalized RVGE (rotavirus gastroenteritis) episode ranged from EUR 1942 in the United Kingdom to EUR 2389 in Sweden [6,7].
In Central Europe, countries bordering Romania have an average of one RVGE hospitalization cost of EUR 316 for Hungary, EUR 741 for Poland [8].
In Romania, two studies have analyzed the hospitalization costs associated with rotavirus gastroenteritis. The first, conducted in Sibiu county and published in 2012, reported that the cost per hospitalization episode ranged from EUR 58.6 to EUR 1243.02 [9]. The second study, carried out in Bucharest over a six-month period from January to June 2011, found that the average hospitalization cost per RVGE case was EUR 581.8, with a mean hospital stay of 6.4 days [10]. A Romanian health economic model (2014) indicated that rotavirus vaccination could prevent a substantial number of mild to severe cases and generate savings of approximately 2.4 million by reducing hospitalizations, outpatient visits, and parental productivity losses, supporting its cost-effectiveness in Romania [11].
Although there are no recent publications in the medical literature on the economic burden of rotavirus gastroenteritis in Romania, the clinical burden remains substantial, with nearly half of hospitalized infants with acute diarrhea testing positive for rotavirus and a high incidence of severe disease [12]. In Brașov county, two large studies have been recently published in the medical literature on viral gastroenteritis [13,14] that demonstrate a high incidence of rotavirus and other viral gastroenteritis infections in hospitalized children. One study showed that rotavirus is accountable for a substantial proportion of pediatric hospitalizations for acute diarrhea, often exceeding 40% of cases, and that is associated with more severe disease compared to other etiologies [13]. The comparative study further highlights that, alongside rotavirus, adenovirus and norovirus also contribute significantly to the burden of the viral gastroenteritis in hospitalized children, with socio-economic differences influencing clinical outcomes and management [14].
It is well known that viral gastroenteritis—particularly cases caused by rotavirus—remains prevalent in countries that have not yet integrated the rotavirus vaccine into their national immunization programs, with a significant burden in terms of disease severity. A similar trend is observed with other viral agents such as norovirus and adenovirus. Therefore, this study aims to assess the economic burden of rotavirus, adenovirus, and norovirus gastroenteritis by evaluating the direct hospitalization costs in children under 60 months of age in our region.

2. Materials and Methods

This study is retrospective, observational, and included children aged 0–60 months who presented to ER of the Children’s Clinical Hospital of Brasov and were hospitalized during January 2023 and December 2023 for vomiting or loose stools with a positive stool sample for rotavirus, adenovirus or norovirus.
Romania is classified as an upper-middle-income European country, with regional disparities in socioeconomic status, hygiene practices, and access to healthcare services [15]. Although urban centers such as Brașov generally have adequate water and sanitation infrastructure, vulnerable populations may still experience overcrowding, suboptimal hygiene conditions, and delayed healthcare access.
Brasov county has approximately 560,000 inhabitants, including about 32,000 children under 60 months old. The National Institute of Statistics, Brașov County Directorate of Statistics, states that in October 2024 the average net salary in Brașov was RON 4921 (almost EUR 984). Additionally, the official data show that 3.4% of Brașov County’s population is of Roma ethnicity; however, previous studies indicate a higher percentage, as many Roma citizens choose not to declare their ethnicity [14].
The hospital is the sole pediatric and referral center in the region, with around 200 beds and an average of 9000 admissions per year out of which ±7500 hospitalized children annually were aged 0–60 months.
Stool samples were analyzed using immunochromatographic methods with professional in vitro diagnostic tests. For the detection of rotavirus and adenovirus, the Rotavirus and Adenovirus Combo Rapid Test Cassette (Today Laboratories, Bucharest, Romania) was used [16]. For Norovirus detection, the NADAL@ Norovirus GI/GII Cassette Test (Moers, Germany) was employed [17].
Exclusion criteria: children > 60 months, stool coinfections, acute comorbidities, hospital-acquired gastroenteritis.
Statistical analysis was performed using Microsoft Excel (Office 365), Python 3.11 (SciPy and scikit-posthocs). Continuous variables (age, duration of hospitalization, and direct hospital costs) were initially examined for normal distribution with the Shapiro–Wilk test. Because distribution was highly skewed in both hospital costs and most continuous variables, median and interquartile range were calculated, and three viral etiologies (rotavirus, adenovirus, norovirus) were compared with the non-parametric Kruskal–Wallis test. When the global test was significant, pairwise post hoc comparisons between pathogens were performed with Dunn’s test with Bonferroni correction for multiple testing.

3. Results

3.1. Patients’ Characteristics

Among the 1041 rotavirus, adenovirus, and norovirus tests performed for the study cohort, 522 were positive for rotavirus, 137 for adenovirus, and 81 for norovirus. After applying the exclusion criteria, 218 children with rotavirus infection, 35 with adenovirus infection, and 29 with norovirus infection were included in the final analysis. A total of 282 children were included in this study. The demographic and clinical characteristics of patients with rotavirus, adenovirus, and norovirus gastroenteritis are summarized in Table 1.
Table 1. Sex distribution, age, residence, ethnicity, maternal age, and length of hospitalization (±standard deviation) among patients with rotavirus, adenovirus, and norovirus gastroenteritis.
Global comparisons were performed using the Kruskal–Wallis test. A statistically significant difference between groups was observed for age (p < 0.01), whereas no significant difference was found for length of hospitalization (p = 0.95).
Severe dehydration was most frequent among children with rotavirus infection (51.3%), compared with adenovirus (40%) and norovirus (24,2%), while mild dehydration was more commonly observed in norovirus cases (37.9%) Table 2.
Table 2. Severity of dehydration for each viral stool pathogen tested.

3.2. Viral Gastroenteritis Hospitalization Direct Costs

In 2023 the direct cost for rotavirus gastroenteritis hospitalizations was EUR 99,549.70 for 218 hospitalizations, for adenovirus gastroenteritis it was EUR 75.118 for 35 hospitalizations and for norovirus gastroenteritis it was EUR 64.877 for 29 hospitalizations.
The analysis has been corrected to a global 3-group non-parametric test (Kruskal–Wallis), with appropriate multiple-comparison post hoc tests (Dunn + Bonferroni), and the conclusion is that costs do not differ significantly among the three virus groups (p = 0.93). Continuous variables are presented as median (P25, P75). Direct hospitalization costs did not differ between rotavirus, adenovirus, and norovirus infections (Kruskal–Wallis H(2) = 0.145, p = 0.930). Duration of hospitalization was also similar across groups (Kruskal–Wallis H(2) = 0.091, p = 0.956). Age differed significantly between pathogens (Kruskal–Wallis H(2) = 9.321, p = 0.00946) Table 3.
Table 3. Hospital costs, hospitalization days, and age by viral etiology. Values are expressed as median (P25–P75). Comparisons were conducted using the Kruskal–Wallis test.
Below are the complete Kruskal–Wallis outputs (global-3-group comparisons) Table 4.
Table 4. Complete Kruskal–Wallis outputs (global-3-group-comparisons).
For Kruskal–Wallis, the degrees of freedom are df = k − 1, so with three pathogens, df = 2.

4. Discussion

In our study, among the three viral etiologies examined—rotavirus, adenovirus, and norovirus—rotavirus displayed a significantly higher frequency than adenovirus or norovirus. The disparity is evident, given the equal number of tests performed. Data from the European Union indicate that norovirus accounts for approximately 18% of acute gastroenteritis hospitalizations in children under five, compared with 48% for rotavirus [18].
From a demographic perspective, boys were more numerous in all three age groups, children of Romanian ethnicity were more frequent across all compared groups, and the average age of the primary caregiver (mother) was similar in all children as well. Comparable patterns have been reported in European cohorts, with male predominance in pediatric viral gastroenteritis (e.g., 55–56% male in an Italian multipathogen cohort [19].
The same primary-care cohort in Italy found similar caregiver impact across rotavirus, norovirus, and adenovirus (e.g., comparable days of work lost by mothers), supporting the notion that caregiver characteristics/burdens do not meaningfully differ by pathogen [19].
The mean duration of hospitalization was comparable for the three pathogens, at approximately 4.5 days. European studies generally report short, similar lengths of stay across viral etiologies, often around 3–5 days. In Ukraine, surveillance of hospitalized children with rotavirus gastroenteritis indicates a typical hospital stay for approximately 4 days, consistent with broader European data [20]. In Northern Eastern Poland, similar durations have been reported for rotavirus and norovirus infections [21].
The average hospitalization cost for viral gastroenteritis in our hospital is approximately EUR 400, with the highest costs incurred for rotavirus infections, followed by norovirus and then adenovirus. Although the mean length of hospitalization was similar across the three viral pathogens, it was slightly longer for rotavirus gastroenteritis. Coupled with the fact that rotavirus accounted for the greatest number of cases during the study period, this underscores rotavirus disease in children under five years as imposing the most significant economic, physical and familial burden. Moreover, rotavirus gastroenteritis is a vaccine-preventable disease. Several European countries have integrated rotavirus vaccination into their national immunization programs, with substantial benefits: universal vaccination has prevented between 72,000 and 144,000 rotavirus-related hospitalizations annually across Europe via up to 96% vaccine effectiveness in children under one year [22].
Studies from Spain and Germany have shown that routine vaccination could substantially reduce disease burden and costs. In Spain, universal vaccination could prevent over 136,000 rotavirus gastroenteritis cases annually and save EUR 22 million from a health service perspective and EUR 38 million from a societal perspective [23]. In Germany, routine rotavirus vaccination could generate cost savings of EUR 6.9–9.2 million per birth cohort, offsetting healthcare and productivity losses [24]. In Romania, the health economic model published in 2014 estimated that rotavirus vaccination could avert a substantial number of mild to severe cases and result in savings of approximately 2.4 million by reducing hospitalizations, outpatient visits, and losses in parental productivity, thereby supporting the cost-effectiveness of vaccination [11].
Together, these findings demonstrate that rotavirus vaccination not only reduces hospitalizations and healthcare utilization but also substantially alleviates economic burden.
Among patients with rotavirus infection (n = 218), over half presented with severe dehydration (51.3%), whereas moderate dehydration was most common in adenovirus infections (40%). In contrast, norovirus infections showed a higher proportion of mild and moderate dehydration (each 37.9%) and the lowest rate of severe dehydration (24.2%). Additionally, the observed high burden of moderate to severe dehydration, particularly in rotavirus infections, suggests a considerable disease burden and indicates that the implementation of rotavirus vaccination may contribute to reducing morbidity and potentially lowering healthcare utilization and related economic costs at the national level.
When placed in an economic context, the average hospitalization cost for rotavirus represents nearly half of the average monthly net salary in Brasov County (approximately EUR 984 in October 2024), underscoring the potential financial strain on the healthcare system and society. Given that rotavirus is a vaccine-preventable disease not yet included in the national immunization program, these findings suggest that rotavirus gastroenteritis may contribute disproportionately to direct hospitalization costs, supporting the consideration of vaccination as a potential strategy to reduce both clinical and economic burden.
The present study has several limitations that should be acknowledged. First, the study populations were not equivalent in size or composition, which may affect the robustness of comparisons. Second, the lack of PCR confirmation may have led to underestimation of the true number of cases included. In addition, the economic evaluation did not account for specific costs related to maternal hospitalizations, medication expenses, or a detailed breakdown of hospital charges. Furthermore, indirect costs were not considered, such as parental workday loss, emotional distress within the family when a child is hospitalized, and broader societal impacts associated with the hospitalization of a child with viral gastroenteritis. Other potential limitations include the single-center design, which may limit generalizability, and the retrospective nature of data collection, which could introduce information bias. These limitations highlight the need for future studies to address these issues through larger, more representative populations, molecular confirmation of cases, and comprehensive inclusion of both direct and indirect costs.

5. Conclusions

The findings of our study underline the significant economic burden of pediatric viral gastroenteritis in Brasov, Romania, and emphasize the need for preventive strategies, such as vaccination, to reduce the financial and clinical impact. The cost analysis in our study has been corrected with Kruskal–Wallis test, with appropriate multiple-comparison post hoc tests (Dunn + Bonferroni), and the conclusion is that costs do not differ significantly among the three virus groups, but rotavirus displayed a significantly higher frequency than adenovirus or norovirus, and a more severe dehydration in children under 60 months in Brasov, Romania.

Author Contributions

Conceptualization, I.A. and O.F.-P.; methodology, I.A.; software, V.M.; validation, I.A., O.F.-P. and B.E.P.; formal analysis, I.-R.L.; investigation, G.C. and I.A.; resources, G.C. and I.A.; data curation, B.E.P.; writing—original draft preparation, I.A.; writing—review and editing, I.A. and O.F.-P.; visualization, O.F.-P.; supervision, O.F.-P.; project administration, I.A. All authors have read and agreed to the published version of the manuscript.

Funding

This research received no external funding.

Institutional Review Board Statement

This study was conducted in accordance with the Declaration of Helsinki and approved by the Institutional Ethics Committee of Children’s Clinical Hospital of Brasov, number of approval: 9/22688; date of approval: 6 November 2025.

Data Availability Statement

All data is available in this study.

Conflicts of Interest

The authors declare no conflicts of interest.

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