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Weldegebriel GG, Okot C, Majingo N, Oumer NJ, Mokomane M, Monyatsi NJ, Phologolo TM, Visagie L, Moakofh K, Seobakeng M, Masresha BG, Seheri M, Mihigo R, Mwenda JM. Resurgent rotavirus diarrhoea outbreak five years after introduction of rotavirus vaccine in Botswana, 2018. Vaccine 2024; 42:1534-1541. [PMID: 38331661 PMCID: PMC10953700 DOI: 10.1016/j.vaccine.2024.01.084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 01/20/2024] [Accepted: 01/25/2024] [Indexed: 02/10/2024]
Abstract
INTRODUCTION Botswana had a resurgent diarrhea outbreak in 2018, mainly affecting children under five years old. Botswana introduced rotavirus vaccine (RotarixTM) into the national immunization programme in July 2012. Official rotavirus vaccine coverage estimates averaged 77.2% over the five years following introduction. MATERIALS AND METHODS The outbreak was investigated using multiple data sources, including stool laboratory testing, immunization data review, water assessment, and vaccine storage assessment. We reviewed official reports of the routine immunization data from 2013 to 2017 and compared district-level rotavirus vaccine coverage with district-level attack rates during the outbreak. RESULTS During the outbreak, a total of 228 stool samples were tested at the national health laboratory and 152 (67%) of the specimens were positive for rotavirus. A portion of adequate samples (80) were selected for referral to the Regional Reference Lab. The laboratory testing of 80 samples at the Regional Reference Laboratory in South Africa showed that 91% of the stool samples were positive for rotavirus, and the dominant strain 47/80 (58.7%) was G3P[8]. The immunization data showed that rotavirus vaccine coverage varied widely among districts, and there was no correlation between districts with high attack rates and those with low immunization coverage. Water assessment showed that some water sources were contaminated with E Coli. There was no problem with vaccine storage. CONCLUSION The outbreak was caused by rotavirus G3P[8], a strain that was not common in the country prior to the outbreak. Despite the significant pressure and anxiety that outbreaks cause, the number of diarrhea cases and deaths were less compared to pre-vaccine era due to the impact of vaccination. This highlights the need for continuous implementation of high impact child survival interventions.
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Affiliation(s)
- Goitom G Weldegebriel
- World Health Organization, Intercountry Support Team, East and Southern Africa, Harare, Zimbabwe.
| | - Charles Okot
- World Health Organization African Regional Office, Brazzaville, Congo
| | | | | | | | | | | | | | | | | | - Balcha G Masresha
- World Health Organization African Regional Office, Brazzaville, Congo
| | - Mapaseka Seheri
- Department of Virology, Sefako Makgatho Health Sciences University, Pretoria, South Africa
| | - Richard Mihigo
- World Health Organization African Regional Office, Brazzaville, Congo
| | - Jason M Mwenda
- World Health Organization African Regional Office, Brazzaville, Congo
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Mohy A, Page N, Boyce W, Gomez JA. Economic Evaluation of Rotavirus Vaccination in Children Aged Under Five Years in South Africa. Clin Drug Investig 2023; 43:851-863. [PMID: 37831397 PMCID: PMC10632264 DOI: 10.1007/s40261-023-01312-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/28/2023] [Indexed: 10/14/2023]
Abstract
BACKGROUND AND OBJECTIVE Evidence on the economic value of rotavirus vaccines in middle-income countries is limited. We aimed to model the implementation of three vaccines (human rotavirus, live, attenuated, oral vaccine [HRV, 2 doses]; rotavirus vaccine, live, oral, pentavalent [HBRV, 3 doses] and rotavirus vaccine, live attenuated oral, freeze-dried [BRV-PV, 3 doses] presented in 1-dose and 2-dose vials) into the South African National Immunisation Programme. METHODS Cost and cost-effectiveness analyses were conducted to compare three rotavirus vaccines using a static, deterministic, population model in children aged <5 years in South Africa from country payer and societal perspectives. Deterministic and probabilistic sensitivity analyses were conducted to assess the impact of uncertainty in model inputs. RESULTS The human rotavirus, live, attenuated, oral vaccine (HRV) was associated with cost savings versus HBRV from both perspectives, and versus BRV-PV 1-dose vial from the societal perspective. In the cost-effectiveness analysis, HRV was estimated to avoid 1,107 home care rotavirus gastroenteritis (RVGE) events, 247 medical visits, 35 hospitalisations, and 4 RVGE-related deaths versus HBRV and BRV-PV. This translated to 73 quality-adjusted life years gained. HRV was associated with lower costs versus HBRV from both payer (-$3.9M) and societal (-$11.5M) perspectives and versus BRV-PV 1-dose vial from the societal perspective (-$3.8M), dominating those options. HRV was associated with higher costs versus BRV-PV 1-dose vial from the payer perspective and versus BRV-PV 2‑dose vial from both payer and societal perspectives (ICERs: $51,834, $121,171, and $16,717, respectively), exceeding the assumed cost-effectiveness threshold of 0.5 GDP per capita. CONCLUSION Vaccination with a 2-dose schedule of HRV may lead to better health outcomes for children in South Africa compared with the 3-dose schedule rotavirus vaccines.
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Affiliation(s)
- Ahmed Mohy
- GSK, Value Evidence and Outcomes, Emerging Markets, GSK Vaccines, Wavre, Belgium.
| | - Nicola Page
- Center for Enteric Diseases, National Institute for Communicable Diseases (NICD), A Division of the National Health Laboratory Service, Johannesburg, South Africa
- Department of Medical Virology, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
| | | | - Jorge A Gomez
- GSK, Value Evidence and Outcomes, Emerging Markets, Buenos Aires, Argentina
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Johnstone SL, Erasmus L, Thomas J, Groome MJ, du Plessis NM, Avenant T, de Villiers M, Page NA. Epidemiology and aetiology of moderate to severe diarrhoea in hospitalised patients ≥5 years old living with HIV in South Africa, 2018-2021: A case-control analysis. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0001718. [PMID: 37682831 PMCID: PMC10490993 DOI: 10.1371/journal.pgph.0001718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 08/07/2023] [Indexed: 09/10/2023]
Abstract
Diarrhoea is a recognised complication of HIV-infection, yet there are limited local aetiological data in this high-risk group. These data are important for informing public health interventions and updating diagnostic and treatment guidelines. This study aimed to determine the pathogenic causes of diarrhoeal admissions in people living with HIV (PLHIV) compared to hospital controls between July 2018 and November 2021. Admitted diarrhoeal cases (n = 243) and non-diarrhoeal hospital controls (n = 101) ≥5 years of age were enrolled at Kalafong, Mapulaneng and Matikwana hospitals. Stool specimens/rectal swabs were collected and pathogen screening was performed on multiple platforms. Differences in pathogen detections between cases and controls, stratified by HIV status, were investigated. The majority (n = 164, 67.5%) of enrolled diarrhoeal cases with known HIV status were HIV-infected. Pathogens could be detected in 66.3% (n = 228) of specimens, with significantly higher detection in cases compared to controls (72.8% versus 50.5%, p<0.001). Amongst PLHIV, prevalence of Cystoisospora spp. was significantly higher in cases than controls (17.7% versus 0.0%, p = 0.028), while Schistosoma was detected more often in controls than cases (17.4% versus 2.4%, p = 0.009). Amongst the HIV-uninfected participants, prevalence of Shigella spp., Salmonella spp. and Helicobacter pylori was significantly higher in cases compared to controls (36.7% versus 12.0%, p = 0.002; 11.4% versus 0.0%, p = 0.012; 10.1% versus 0.0%, p = 0.023). Diarrhoeal aetiology differed by HIV status, with Shigella spp. (36.7%) and Salmonella spp. (11.4%) having the highest prevalence amongst HIV-uninfected cases and Shigella spp. (18.3%), Cystoisospora (17.7%), and Cryptosporidium spp. (15.9%) having the highest prevalence in cases amongst PLHIV. These differences should be considered for the development of diagnostic and treatment guidelines.
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Affiliation(s)
- Siobhan L. Johnstone
- Center for Enteric Diseases, National Institute for Communicable Diseases, A Division of the National Health Laboratory Service (NHLS), Johannesburg, South Africa
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Linda Erasmus
- Center for Enteric Diseases, National Institute for Communicable Diseases, A Division of the National Health Laboratory Service (NHLS), Johannesburg, South Africa
| | - Juno Thomas
- Center for Enteric Diseases, National Institute for Communicable Diseases, A Division of the National Health Laboratory Service (NHLS), Johannesburg, South Africa
| | - Michelle J. Groome
- Division of Public Health Surveillance and Response, National Institute for Communicable Diseases, A Division of the National Health Laboratory Service (NHLS), Johannesburg, South Africa
- School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Nicolette M. du Plessis
- Department of Paediatrics, Kalafong Provincial Tertiary Hospital, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
| | - Theunis Avenant
- Department of Paediatrics, Kalafong Provincial Tertiary Hospital, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
| | - Maryke de Villiers
- Department of Internal Medicine, Kalafong Provincial Tertiary Hospital, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
| | - Nicola A. Page
- Center for Enteric Diseases, National Institute for Communicable Diseases, A Division of the National Health Laboratory Service (NHLS), Johannesburg, South Africa
- Department of Medical Virology, Faculty of Health Sciences, University of Pretoria, Pretoria, Arcadia, South Africa
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4
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Mafokwane T, Djikeng A, Nesengani LT, Dewar J, Mapholi O. Gastrointestinal Infection in South African Children under the Age of 5 years: A Mini Review. Gastroenterol Res Pract 2023; 2023:1906782. [PMID: 37663241 PMCID: PMC10469397 DOI: 10.1155/2023/1906782] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 07/14/2023] [Accepted: 07/24/2023] [Indexed: 09/05/2023] Open
Abstract
Objective To estimate gastroenteritis disease and its etiological agents in children under the age of 5 years living in South Africa. Methods A mini literature review of pertinent articles published in ScienceDirect, PubMed, GoogleScholar, and Scopus was conducted using search terms: "Gastroenteritis in children," "Gastroenteritis in the world," Gastroenteritis in South Africa," "Prevalence of gastroenteritis," "Epidemiological surveillance of gastroenteritis in the world," and "Causes of gastroenteritis". Results A total of 174 published articles were included in this mini review. In the last 20 years, the mortality rate resulting from diarrhea in children under the age of 5 years has declined and this is influenced by improved hygiene practices, awareness programs, an improved water and sanitation supply, and the availability of vaccines. More modern genomic amplification techniques were used to re-analyze stool specimens collected from children in eight low-resource settings in Asia, South America, and Africa reported improved sensitivity of pathogen detection to about 65%, that viruses were the main etiological agents in patients with diarrhea aged from 0 to 11 months but that Shigella, followed by sapovirus and enterotoxigenic Escherichia coli had a high incidence in children aged 12-24 months. In addition, co-infections were noted in nearly 10% of diarrhea cases, with rotavirus and Shigella being the main co-infecting agents together with adenovirus, enteropathogenic E. coli, Clostridium jejuni, or Clostridium coli. Conclusions This mini review outlines the epidemiology and trends relating to parasitic, viral, and bacterial agents responsible for gastroenteritis in children in South Africa. An increase in sequence-independent diagnostic approaches will improve the identification of pathogens to resolve undiagnosed cases of gastroenteritis. Emerging state and national surveillance systems should focus on improving the identification of gastrointestinal pathogens in children and the development of further vaccines against gastrointestinal pathogens.
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Affiliation(s)
- Tshepo Mafokwane
- Department of Life and Consumer Sciences, College of Agriculture and Environmental Sciences, University of South Africa, Science Campus, Florida, Johannesburg, South Africa
| | - Appolinaire Djikeng
- Department of Agriculture, College of Agriculture and Environmental Sciences, University of South Africa Science Campus, Florida, Johannesburg, South Africa
- Centre for Tropical Livestock Genetics and Health (CTLGH), Royal (Dick) School of Veterinary Studies, University of Edinburgh, Edinburgh, UK
| | - Lucky T. Nesengani
- Department of Agriculture, College of Agriculture and Environmental Sciences, University of South Africa Science Campus, Florida, Johannesburg, South Africa
| | - John Dewar
- Department of Life and Consumer Sciences, College of Agriculture and Environmental Sciences, University of South Africa, Science Campus, Florida, Johannesburg, South Africa
| | - Olivia Mapholi
- Department of Agriculture, College of Agriculture and Environmental Sciences, University of South Africa Science Campus, Florida, Johannesburg, South Africa
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5
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Tate JE, Cortese MM, Offit PA, Parashar UD. Rotavirus Vaccines. PLOTKIN'S VACCINES 2023:1005-1024.e11. [DOI: 10.1016/b978-0-323-79058-1.00053-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2025]
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Malebatja MF, Mokgatle MM. Diarrhoea among Children Aged 5 Years and Microbial Drinking Water Quality Compliance: Trends Analysis Study in South Africa (2008-2018). INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 20:598. [PMID: 36612920 PMCID: PMC9819380 DOI: 10.3390/ijerph20010598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 12/23/2022] [Accepted: 12/26/2022] [Indexed: 06/17/2023]
Abstract
In developing countries such as South Africa, diarrhoeal diseases are reported to be linked to inadequate drinking water quality, sanitation, and hygiene behaviours. The consumption of microbiologically contaminated drinking water has been reported to cause diarrhoea, mortality, and morbidity in children under the age of five years. This study evaluated the microbiological pathogens detected in municipal drinking water and diarrhoea trends for children under 5 years of age in South Africa between 2008 and 2018. A trends analysis study was conducted using secondary data on diarrhoea for children under the age of five years and microbial drinking water quality compliance. A negative correlation was found between the occurrence of microbial pathogens in water, morbidity, and mortality rates of children under the age of 5 years in South Africa. As compliance status improved, the mortality rate among children under 5 years old decreased by 31% over the study period. A conclusion can thus be drawn that the microbiological pathogens detected in drinking water at levels complying with SANS 241:2015 Edition 2 standards and diarrhoea incidences were not the primary cause of the mortality of children under 5 years old in South Africa between 2008 and 2018.
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Affiliation(s)
- Mohora Feida Malebatja
- Environmental and Occupational Health Department, Health Sciences Faculty, School of Health Systems and Public Health, University of Pretoria, Private Bag X 20, Hatfield, Pretoria 0028, South Africa
- Environmental and Occupational Health Division, Public Health Department, School of Healthcare Sciences, Sefako Makgatho Health Sciences University, Pretoria Ga-Rankuwa, Pretoria 0208, South Africa
| | - Mpata Mathildah Mokgatle
- Environmental and Occupational Health Division, Public Health Department, School of Healthcare Sciences, Sefako Makgatho Health Sciences University, Pretoria Ga-Rankuwa, Pretoria 0208, South Africa
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7
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Evaluating the appropriateness of laboratory testing and antimicrobial use in South African children hospitalized for community-acquired infections. PLoS One 2022; 17:e0272119. [PMID: 35901088 PMCID: PMC9333228 DOI: 10.1371/journal.pone.0272119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 07/13/2022] [Indexed: 11/22/2022] Open
Abstract
Introduction Community acquired infection (CAI) is the leading indication for paediatric hospitalization in South Africa. Methods We conducted secondary data analysis of prospective, consecutive paediatric admissions to Tygerberg Hospital (May 2015-November 2015). Clinical characteristics, admission diagnosis, appropriateness of diagnostic tests, use of antimicrobial prescriptions, hospital outcome and costs were analyzed. Results CAI episodes were documented in (364/451; 81%) children admitted to the general paediatric ward; median age 4.8 months (Interquartile range, IQR, 1.5–17.5) and weight 5.4kg (IQR, 3.6–9.0). Male gender predominated (210/364; 58%), and Human Immunodeficiency Virus infection prevalence was 6.0% (22/364). Common CAI types included respiratory tract infections (197; 54%), gastroenteritis (51; 14%), and bloodstream infections (33; 9%). Pre-hospital antibiotics (ceftriaxone) were given to 152/364 (42%). Of 274 blood cultures and 140 cerebrospinal fluid samples submitted, 5% and 2% respectively yielded a pathogen. Common CAI antibiotic treatment regimens included: ampicillin alone (53%); ampicillin plus gentamicin (25%) and ampicillin plus cefotaxime (20%). Respiratory syncytial virus (RSV) was found in 39% of the children investigated for pneumonia. Most antibiotic prescriptions (323/364; 89%) complied with national guidelines and were appropriately adjusted based on the patient’s clinical condition and laboratory findings. The overall estimated cost of CAI episode management ZAR 22,535 (≈1423 USD) per CAI admission episode. Unfavourable outcomes were uncommon (1% died, 4% required re-admission within 30 days of discharge). Conclusion CAI is the most frequent reason for hospitalization and drives antimicrobial use. Improved diagnostic stewardship is needed to prevent inappropriate antimicrobial prescriptions. Clinical outcome of paediatric CAI episodes was generally favourable.
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8
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Mwangi PN, Page NA, Seheri ML, Mphahlele MJ, Nadan S, Esona MD, Kumwenda B, Kamng'ona AW, Donato CM, Steele DA, Ndze VN, Dennis FE, Jere KC, Nyaga MM. Evolutionary changes between pre- and post-vaccine South African group A G2P[4] rotavirus strains, 2003-2017. Microb Genom 2022; 8. [PMID: 35446251 PMCID: PMC9453071 DOI: 10.1099/mgen.0.000809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
The transient upsurge of G2P[4] group A rotavirus (RVA) after Rotarix vaccine introduction in several countries has been a matter of concern. To gain insight into the diversity and evolution of G2P[4] strains in South Africa pre- and post-RVA vaccination introduction, whole-genome sequencing was performed for RVA positive faecal specimens collected between 2003 and 2017 and samples previously sequenced were obtained from GenBank (n=103; 56 pre- and 47 post-vaccine). Pre-vaccine G2 sequences predominantly clustered within sub-lineage IVa-1. In contrast, post-vaccine G2 sequences clustered mainly within sub-lineage IVa-3, whereby a radical amino acid (AA) substitution, S15F, was observed between the two sub-lineages. Pre-vaccine P[4] sequences predominantly segregated within sub-lineage IVa while post-vaccine sequences clustered mostly within sub-lineage IVb, with a radical AA substitution R162G. Both S15F and R162G occurred outside recognised antigenic sites. The AA residue at position 15 is found within the signal sequence domain of Viral Protein 7 (VP7) involved in translocation of VP7 into endoplasmic reticulum during infection process. The 162 AA residue lies within the hemagglutination domain of Viral Protein 4 (VP4) engaged in interaction with sialic acid-containing structure during attachment to the target cell. Free energy change analysis on VP7 indicated accumulation of stable point mutations in both antigenic and non-antigenic regions. The segregation of South African G2P[4] strains into pre- and post-vaccination sub-lineages is likely due to erstwhile hypothesized stepwise lineage/sub-lineage evolution of G2P[4] strains rather than RVA vaccine introduction. Our findings reinforce the need for continuous whole-genome RVA surveillance and investigation of contribution of AA substitutions in understanding the dynamic G2P[4] epidemiology.
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Affiliation(s)
- Peter N Mwangi
- Next Generation Sequencing Unit and Division of Virology, Faculty of Health Sciences, University of the Free State, Bloemfontein 9300, South Africa
| | - Nicola A Page
- Centre for Enteric Disease, National Institute for Communicable Diseases, Private Bag X4, Sandringham, 2131, Johannesburg, South Africa.,Department of Medical Virology, Faculty of Health Sciences, University of Pretoria, Private Bag X323, Arcadia, 0007, Pretoria, South Africa
| | - Mapaseka L Seheri
- Diarrheal Pathogens Research Unit, Sefako Makgatho Health Sciences University, Medunsa 0204, Pretoria, South Africa
| | - M Jeffrey Mphahlele
- Diarrheal Pathogens Research Unit, Sefako Makgatho Health Sciences University, Medunsa 0204, Pretoria, South Africa.,Office of the Deputy Vice Chancellor for Research and Innovation, North-West University, Potchefstroom 2351, South Africa.,South African Medical Research Council, Pretoria 0001, South Africa
| | - Sandrama Nadan
- Centre for Enteric Disease, National Institute for Communicable Diseases, Private Bag X4, Sandringham, 2131, Johannesburg, South Africa
| | - Mathew D Esona
- Diarrheal Pathogens Research Unit, Sefako Makgatho Health Sciences University, Medunsa 0204, Pretoria, South Africa
| | - Benjamin Kumwenda
- Department of Biomedical Sciences, School of Life Sciences and Applied Health Professions, Kamuzu University of Health Sciences, Private Bag 360, Chichiri, Blantyre 3, Malawi
| | - Arox W Kamng'ona
- Department of Biomedical Sciences, School of Life Sciences and Applied Health Professions, Kamuzu University of Health Sciences, Private Bag 360, Chichiri, Blantyre 3, Malawi
| | - Celeste M Donato
- Department of Medical Laboratory Sciences, School of Life Sciences and Applied Health Professions, Kamuzu University of Health Sciences, Private Bag 360, Chichiri, Blantyre3, Malawi.,Enteric Diseases Group, Murdoch Children's Research Institute, 50 Flemington Road, Parkville, Melboune 3052, Australia.,Department of Paediatrics, the University of Melbourne, Parkville 3010, Australia
| | - Duncan A Steele
- Diarrheal Pathogens Research Unit, Sefako Makgatho Health Sciences University, Medunsa 0204, Pretoria, South Africa
| | - Valantine N Ndze
- Faculty of Health Sciences, University of Buea, P.O Box 63 Buea, Cameroon
| | - Francis E Dennis
- Department of Electron Microscopy and Histopathology, Noguchi Memorial Institute for Medical Research, University of Ghana, P.O Box LG581, Legon, Ghana
| | - Khuzwayo C Jere
- Center for Global Vaccine Research, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, L697BE, Liverpool, UK.,Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre 312225, Malawi
| | - Martin M Nyaga
- Next Generation Sequencing Unit and Division of Virology, Faculty of Health Sciences, University of the Free State, Bloemfontein 9300, South Africa
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Howard W, Savulescu D, Berrie L, Puren AJ. Description of non-polio enteroviruses identified in two national surveillance programmes in South Africa. S Afr J Infect Dis 2021; 35:196. [PMID: 34485481 PMCID: PMC8378180 DOI: 10.4102/sajid.v35i1.196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Accepted: 09/29/2020] [Indexed: 11/23/2022] Open
Abstract
Background Human enteroviruses (EV) consist of 106 serotypes and four species: EV-A, EV-B, EV-C and EV-D. Enteroviruses cause clinical symptoms varying from severe to mild. Knowledge of EV burden in South Africa is limited, and as non-polio EV are important causes of acute flaccid paralysis (AFP) and meningitis, information on the circulating serotypes is vital. Methods Between 2010 and 2012, a total of 832 stool and viral isolate specimens were obtained from two national surveillance programmes at the National Institute for Communicable Diseases: the Rotavirus Sentinel Surveillance Programme (RSSP) and the AFP surveillance programme. Real-time polymerase chain reaction and Sanger sequencing were performed to detect and serotype EV. Results Non-polio EV were detected in 446 specimens, of which 308 were sequenced. Stool specimens yielded a greater variety of serotypes than viral cultures. EV-B viruses were predominant (58.44%), whilst EV-C viruses were detected in 31% of the specimens tested. South African prevalence for these viruses was higher than other countries, such as France with less than 2%, and Spain and the United States with less than 10%. The most common serotype detected was Enterovirus 99 (EV-C, 8.63%), which has not been reported in other regions. Conclusion Direct sequencing from stool specimens yields a broader, more comprehensive description of EV infections compared to sequencing from viral cultures. Disease-associated serotypes were detected, but only in small numbers. This study provides a baseline for EV strain circulation; however, surveillance needs to be expanded to improve EV knowledge in South Africa.
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Affiliation(s)
- Wayne Howard
- National Institute for Communicable Diseases, Johannesburg, South Africa.,Faculty of Health, University of Witwatersrand, Johannesburg, South Africa
| | - Dana Savulescu
- National Institute for Communicable Diseases, Johannesburg, South Africa
| | - Leigh Berrie
- Faculty of Health, University of Witwatersrand, Johannesburg, South Africa.,National Priority Programmes, National Health Laboratory Services, Johannesburg, South Africa
| | - Adrian J Puren
- National Institute for Communicable Diseases, Johannesburg, South Africa.,Faculty of Health, University of Witwatersrand, Johannesburg, South Africa
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10
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Ghapoutsa RN, Boda M, Gautam R, Ndze VN, Mugyia AE, Etoa FX, Bowen MD, Esona MD. Detection of diarrhoea associated rotavirus and co-infection with diarrhoeagenic pathogens in the Littoral region of Cameroon using ELISA, RT-PCR and Luminex xTAG GPP assays. BMC Infect Dis 2021; 21:614. [PMID: 34182936 PMCID: PMC8237514 DOI: 10.1186/s12879-021-06318-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 06/14/2021] [Indexed: 12/16/2022] Open
Abstract
Background Despite the global roll-out of rotavirus vaccines (RotaTeq/Rotarix / ROTAVAC/Rotasiil), mortality and morbidity due to group A rotavirus (RVA) remains high in sub-Saharan Africa, causing 104,000 deaths and 600,000 hospitalizations yearly. In Cameroon, Rotarix™ was introduced in March 2014, but, routine laboratory diagnosis of rotavirus infection is not yet a common practice, and vaccine effectiveness studies to determine the impact of vaccine introduction have not been done. Thus, studies examining RVA prevalence post vaccine introduction are needed. The study aim was to determine RVA prevalence in severe diarrhoea cases in Littoral region, Cameroon and investigate the role of other diarrheagenic pathogens in RVA-positive cases. Methods We carried out a study among hospitalized children < 5 years of age, presenting with acute gastroenteritis in selected hospitals of the Littoral region of Cameroon, from May 2015 to April 2016. Diarrheic stool samples and socio-demographic data including immunization and breastfeeding status were collected from these participating children. Samples were screened by ELISA (ProSpecT™ Rotavirus) for detection of RVA antigen and by gel-based RT-PCR for detection of the VP6 gene. Co-infection was assessed by multiplexed molecular detection of diarrheal pathogens using the Luminex xTAG GPP assay. Results The ELISA assay detected RVA antigen in 54.6% (71/130) of specimens, with 45, positive by VP6 RT-PCR and 54, positive using Luminex xTAG GPP. Luminex GPP was able to detect all 45 VP6 RT-PCR positive samples. Co-infections were found in 63.0% (34/54) of Luminex positive RVA infections, with Shigella (35.3%; 12/34) and ETEC (29.4%; 10/34) detected frequently. Of the 71 ELISA positive RVA cases, 57.8% (41/71) were fully vaccinated, receiving two doses of Rotarix. Conclusion This study provides insight on RVA prevalence in Cameroon, which could be useful for post-vaccine epidemiological studies, highlights higher than expected RVA prevalence in vaccinated children hospitalized for diarrhoea and provides the trend of RVA co-infection with other enteric pathogens. RVA genotyping is needed to determine circulating rotavirus genotypes in Cameroon, including those causing disease in vaccinated children.
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Affiliation(s)
- Rahinatou N Ghapoutsa
- Department of Biochemistry, Faculty of Science, The University of Yaoundé 1, Yaoundé, Cameroon
| | - Maurice Boda
- Department of Microbiology, Faculty of Science, The University of Yaoundé 1, Yaoundé, Cameroon.
| | - Rashi Gautam
- Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, Centers for Diseases Control and Prevention, Atlanta, Georgia, USA
| | | | - Akongnwi E Mugyia
- Department of Microbiology and Parasitology, Faculty of Science, University of Buea, Buea, Cameroon
| | - Francois-Xavier Etoa
- Department of Microbiology, Faculty of Science, The University of Yaoundé 1, Yaoundé, Cameroon
| | - Michael D Bowen
- Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, Centers for Diseases Control and Prevention, Atlanta, Georgia, USA
| | - Mathew D Esona
- Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, Centers for Diseases Control and Prevention, Atlanta, Georgia, USA
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Groome MJ, Tate JE, Arnold M, Chitnis M, Cox S, de Vos C, Kirsten M, le Grange SM, Loveland J, Machaea S, Maharaj A, Andrews N, Madhi SA, Parashar UD. Evaluation of Intussusception After Oral Monovalent Rotavirus Vaccination in South Africa. Clin Infect Dis 2021; 70:1606-1612. [PMID: 31125061 PMCID: PMC7146001 DOI: 10.1093/cid/ciz431] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Accepted: 05/22/2019] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Postlicensure studies have shown an association between rotavirus vaccination and intussusception. We assessed the risk of intussusception associated with Rotarix (RV1) administration, at 6 and 14 weeks of age, in an upper-middle-income country, South Africa. METHODS Active prospective surveillance for intussusception was conducted in 8 hospitals from September 2013 through December 2017. Retrospective case enrollment was done at 1 hospital from July 2012 through August 2013. Demographic characteristics, symptom onset, and rotavirus vaccine status were ascertained. Using the self-controlled case-series method, we estimated age-adjusted incidence rate ratios within 1-7, 8-21, and 1-21 days of rotavirus vaccination in children aged 28-275 days at onset of symptoms. In addition, age-matched controls were enrolled for a subset of cases (n = 169), and a secondary analysis was performed. RESULTS Three hundred forty-six cases were included in the case-series analysis. Post-dose 1, there were zero intussusception cases within 1-7 days, and 5 cases within 8-21 days of vaccination. Post-dose 2, 15 cases occurred within 1-7 days, and 18 cases within 8-21 days of vaccination. There was no increased risk of intussusception 1-7 days after dose 1 (no cases observed) or dose 2 (relative incidence [RI], 1.71 [95% confidence interval {CI} .83-3.01]). Similarly, there was no increased risk 8-21 days after the first (RI, 4.01 [95% CI, .87-10.56]) or second dose (RI, .96 [95% CI, .52-1.60]). Results were similar for the case-control analysis. CONCLUSIONS The risk of intussusception in the 21 days after the first or second dose of RV1 was not higher than the background risk among South Africa infants. CLINICAL TRIALS REGISTRATION South African National Clinical Trial Register (DOH-27-0913-4183).
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Affiliation(s)
- Michelle J Groome
- Medical Research Council, Respiratory and Meningeal Pathogens Research Unit, Faculty of Health Sciences.,Department of Science and Technology/National Research Foundation, Vaccine Preventable Diseases, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Marion Arnold
- Red Cross War Memorial Children's Hospital, University of Cape Town.,Tygerberg Hospital, University of Stellenbosch, Cape Town
| | | | - Sharon Cox
- Red Cross War Memorial Children's Hospital, University of Cape Town
| | - Corné de Vos
- Tygerberg Hospital, University of Stellenbosch, Cape Town
| | - Mari Kirsten
- Steve Biko Academic Hospital/Kalafong Hospital, University of Pretoria
| | | | - Jerome Loveland
- Chris Hani Baragwanath Academic Hospital/Charlotte Maxeke Johannesburg Academic Hospital, University of the Witwatersrand, Johannesburg
| | - Sello Machaea
- East London Hospital Complex, Walter Sisulu University
| | - Ashwini Maharaj
- Inkosi Albert Luthuli Hospital, University of Kwa-Zulu Natal, Durban, South Africa
| | - Nick Andrews
- Statistics, Modelling and Economics Department, Public Health England, London, United Kingdom
| | - Shabir A Madhi
- Medical Research Council, Respiratory and Meningeal Pathogens Research Unit, Faculty of Health Sciences.,Department of Science and Technology/National Research Foundation, Vaccine Preventable Diseases, University of the Witwatersrand, Johannesburg, South Africa
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12
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Nadan S, Taylor MB, Page NA. Circulation of classic and recombinant human astroviruses detected in South Africa: 2009 to 2014. J Clin Virol 2020; 135:104719. [PMID: 33388529 DOI: 10.1016/j.jcv.2020.104719] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 11/13/2020] [Accepted: 12/17/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Astroviruses (AstVs) are associated with diarrhoeal and extra-intestinal infections in human, animal and avian species. A prevalence of 7% was reported in selected regions in SA while AstVs detected from clinical stool specimens were almost identical phylogenetically to strains identified in environmental and water samples. This study investigated the molecular diversity of astroviruses circulating between 2009 and 2014 in South Africa (SA). METHODS Astroviruses detected in stool specimens collected from hospitalised children were investigated retrospectively. Astroviruses were characterised using type-specific RT-PCR, partial nucleotide sequence analyses in ORF1 and ORF2 and whole genome sequencing. Different genotypes were compared with clinical features to investigate genotype-related associations. The Vesikari severity scale (VSS) was evaluated for scoring astrovirus diarrhoeal infections. RESULTS Of 405 astroviruses detected, 49.9 % (202/405) were characterised into 32 genotypes comprising 66.3 % (134/202) putative-recombinants and 33.7 % (68/202) classic strains. No trends by year of collection, age or site were observed. Whole genome analysis in eight strains revealed that genotypes assigned by partial nucleotide sequence analyses to five astroviruses were incorrect. Bivariate analyses showed there were no significant associations between genotypes and clinical symptoms or severity of infection. A comparison of Vesikari parameters with astrovirus-positive proxy values demonstrated that Vesikari scores for duration of diarrhoea and admission temperatures would result in a milder infection rating in astrovirus-positive cases. CONCLUSIONS Diverse genotypes co-circulated with putative-recombinants predominating. Astrovirus classification was complicated by the lack of a consistent characterisation system and reliable reference database. The VSS should be used cautiously to rate astrovirus diarrhoea. While surveillance in communities and out-patient clinics must be continued, screening for human astroviruses in alternate hosts is needed to determine the reservoir species.
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Affiliation(s)
- Sandrama Nadan
- Centre for Enteric Diseases, National Institute for Communicable Disease, Private Bag X4, Sandringham, 2131, South Africa.
| | - Maureen B Taylor
- Department of Medical Virology, Faculty of Health Sciences, University of Pretoria, Private Bag X323, Gezina, 0031, South Africa; National Health Laboratory Services, Tshwane Academic Division, Pretoria, South Africa
| | - Nicola A Page
- Centre for Enteric Diseases, National Institute for Communicable Disease, Private Bag X4, Sandringham, 2131, South Africa; Department of Medical Virology, Faculty of Health Sciences, University of Pretoria, Private Bag X323, Gezina, 0031, South Africa
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13
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Ajibola G, Bennett K, Powis KM, Hughes MD, Leidner J, Kgole S, Batlang O, Mmalane M, Makhema J, Lockman S, Shapiro R. Decreased diarrheal and respiratory disease in HIV exposed uninfected children following vaccination with rotavirus and pneumococcal conjugate vaccines. PLoS One 2020; 15:e0244100. [PMID: 33347474 PMCID: PMC7751865 DOI: 10.1371/journal.pone.0244100] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Accepted: 10/29/2020] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Rotavirus vaccine (RV) and pneumococcal vaccine (PCV) decrease diarrheal and respiratory disease incidence and severity, but there are few data about the effects of these vaccines among HIV-exposed uninfected (HEU) children. METHODS We recorded RV and PCV vaccination history in a placebo-controlled trial that studied the need for cotrimoxazole among HEU infants in Botswana (the Mpepu Study). We categorized infants by enrollment before or after the simultaneous April 2012 introduction of RV and PCV, and compared diagnoses of diarrhea and pneumonia (grade 3/4), hospitalizations, and deaths from both disease conditions through the 12-month study visit by vaccine era/status across two sites (a city and a village) by Kaplan-Meier estimates. RESULTS Two thousand six hundred and thirty-five HEU infants were included in this secondary analysis, of these 1689 (64%) were enrolled in Gaborone (344 pre-vaccine, 1345 vaccine) and 946 (36%) in Molepolole (209 pre-vaccine, 737 vaccine). We observed substantial reduction in hazard of hospitalization or death for reason of diarrhea and pneumonia in the vaccine era versus the pre-vaccine era in Molepolole (hazard ratio, HR = 0.44, 95% confidence interval, CI = 0.28, 0.71) with smaller reduction in Gaborone (HR = 0.91, 95% CI = 0.57, 1.45). Similar downward trends were observed for diagnoses of diarrhea and pneumonia separately during the vaccine versus pre-vaccine era. CONCLUSIONS Although temporal confounding cannot be excluded, significant declines in the burden of diarrheal and respiratory illness were observed among HEU children in Botswana following the introduction of RV and PCV. RV and PCV may maximally benefit HEU children in rural areas with higher disease burden.
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Affiliation(s)
| | - Kara Bennett
- Bennett Statistical Consulting, Inc, Ballston Lake, NY, United States of America
| | - Kathleen M. Powis
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
- Departments of Internal Medicine and Pediatrics, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Department of Immunology and Infectious Diseases, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Michael D. Hughes
- Department of Biostatistics, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Jean Leidner
- Goodtables Data Consulting, LLC, Norman, Oklahoma, United States of America
| | - Samuel Kgole
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Oganne Batlang
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Mompati Mmalane
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Joseph Makhema
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Shahin Lockman
- Division of Infectious Disease, Brigham and Women's Hospital, Boston, Massachusetts, United States of America
| | - Roger Shapiro
- Department of Immunology and Infectious Diseases, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, United States of America
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14
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Mwangi PN, Mogotsi MT, Seheri ML, Mphahlele MJ, Peenze I, Esona MD, Kumwenda B, Steele AD, Kirkwood CD, Ndze VN, Dennis FE, Jere KC, Nyaga MM. Whole Genome In-Silico Analysis of South African G1P[8] Rotavirus Strains Before and After Vaccine Introduction Over A Period of 14 Years. Vaccines (Basel) 2020; 8:E609. [PMID: 33066615 PMCID: PMC7712154 DOI: 10.3390/vaccines8040609] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Revised: 10/08/2020] [Accepted: 10/13/2020] [Indexed: 12/03/2022] Open
Abstract
Rotavirus G1P[8] strains account for more than half of the group A rotavirus (RVA) infections in children under five years of age, globally. A total of 103 stool samples previously characterized as G1P[8] and collected seven years before and seven years after introducing the Rotarix® vaccine in South Africa were processed for whole-genome sequencing. All the strains analyzed had a Wa-like constellation (G1-P[8]-I1-R1-C1-M1-A1-N1-T1-E1-H1). South African pre- and post-vaccine G1 strains were clustered in G1 lineage-I and II while the majority (84.2%) of the P[8] strains were grouped in P[8] lineage-III. Several amino acid sites across ten gene segments with the exception of VP7 were under positive selective pressure. Except for the N147D substitution in the antigenic site of eight post-vaccine G1 strains when compared to both Rotarix® and pre-vaccine strains, most of the amino acid substitutions in the antigenic regions of post-vaccine G1P[8] strains were already present during the pre-vaccine period. Therefore, Rotarix® did not appear to have an impact on the amino acid differences in the antigenic regions of South African post-vaccine G1P[8] strains. However, continued whole-genome surveillance of RVA strains to decipher genetic changes in the post-vaccine period remains imperative.
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Affiliation(s)
- Peter N. Mwangi
- Next Generation Sequencing Unit and Division of Virology, Faculty of Health Sciences, University of the Free State, Bloemfontein 9300, South Africa; (P.N.M.); (M.T.M.)
| | - Milton T. Mogotsi
- Next Generation Sequencing Unit and Division of Virology, Faculty of Health Sciences, University of the Free State, Bloemfontein 9300, South Africa; (P.N.M.); (M.T.M.)
| | - Mapaseka L. Seheri
- Diarrheal Pathogens Research Unit, Sefako Makgatho Health Sciences University, Medunsa 0204, South Africa; (M.L.S.); (M.J.M.); (I.P.); (M.D.E.)
| | - M. Jeffrey Mphahlele
- Diarrheal Pathogens Research Unit, Sefako Makgatho Health Sciences University, Medunsa 0204, South Africa; (M.L.S.); (M.J.M.); (I.P.); (M.D.E.)
- South African Medical Research Council, Pretoria 0001, South Africa
| | - Ina Peenze
- Diarrheal Pathogens Research Unit, Sefako Makgatho Health Sciences University, Medunsa 0204, South Africa; (M.L.S.); (M.J.M.); (I.P.); (M.D.E.)
| | - Mathew D. Esona
- Diarrheal Pathogens Research Unit, Sefako Makgatho Health Sciences University, Medunsa 0204, South Africa; (M.L.S.); (M.J.M.); (I.P.); (M.D.E.)
| | - Benjamin Kumwenda
- College of Medicine, Department of Biomedical Sciences, Faculty of Biomedical Sciences and Health Professions, University of Malawi, Private Bag 360, Chichiri, Blantyre 3, Malawi;
| | - A. Duncan Steele
- Enteric and Diarrheal Diseases, Global Health, Bill & Melinda Gates Foundation, P.O. Box 23350, Seattle, WA 98109, USA; (A.D.S.); (C.D.K.)
| | - Carl D. Kirkwood
- Enteric and Diarrheal Diseases, Global Health, Bill & Melinda Gates Foundation, P.O. Box 23350, Seattle, WA 98109, USA; (A.D.S.); (C.D.K.)
| | - Valantine N. Ndze
- Faculty of Health Sciences, University of Buea, P.O. Box 63, Buea, Cameroon;
| | - Francis E. Dennis
- Noguchi Memorial Institute for Medical Research, University of Ghana, P.O. Box LG581, Legon, Ghana;
| | - Khuzwayo C. Jere
- Center for Global Vaccine Research, Institute of Infection, Liverpool L697BE, UK;
- Veterinary and Ecological Sciences, University of Liverpool, Liverpool L697BE, UK
- Malawi-Liverpool-Wellcome Trust Clinical Research Program, Department of Medical Laboratory Sciences, College of Medicine, University of Malawi, Blantyre 312225, Malawi
| | - Martin M. Nyaga
- Next Generation Sequencing Unit and Division of Virology, Faculty of Health Sciences, University of the Free State, Bloemfontein 9300, South Africa; (P.N.M.); (M.T.M.)
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15
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Pereira P, Vetter V, Standaert B, Benninghoff B. Fifteen years of experience with the oral live-attenuated human rotavirus vaccine: reflections on lessons learned. Expert Rev Vaccines 2020; 19:755-769. [PMID: 32729747 DOI: 10.1080/14760584.2020.1800459] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Rotavirus (RV) disease remains a prominent cause of disease burden in children <5 years of age worldwide. However, implementation of RV vaccination has led to significant reductions in RV mortality, compared to the pre-vaccination era. This review presents 15 years of real-world experience with the oral live-attenuated human RV vaccine (HRV; Rotarix). HRV is currently introduced in ≥80 national immunization programs (NIPs), as 2 doses starting from 6 weeks of age. AREAS COVERED The clinical development of HRV and post-marketing experience indicating the impact of HRV vaccination on RV disease was reviewed. EXPERT OPINION In clinical trials, HRV displayed an acceptable safety profile and efficacy against RV-gastroenteritis, providing broad protection against heterotypic RV strains by reducing the consequences of severe RV disease in infants. Real-world evidence shows substantial, rapid reduction in the number of RV infections and associated hospitalizations following introduction of HRV in NIPs, regardless of economic setting. Indirect effects against RV disease are also observed, such as herd protection, decrease in nosocomial infections incidence, and a reduction of disease-related societal/healthcare costs. However, not all countries have implemented RV vaccination. Coverage remains suboptimal and should be improved to maximize the benefits of RV vaccination.
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16
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Shonhiwa AM, Ntshoe G, Crisp N, Olowolagba AJ, Mbuthu V, Taylor MB, Thomas J, Page NA. Investigation of two suspected diarrhoeal-illness outbreaks in Northern Cape and KwaZulu-Natal provinces, South Africa, April-July 2013: The role of rotavirus. S Afr J Infect Dis 2020; 35:159. [PMID: 34485475 PMCID: PMC8378150 DOI: 10.4102/sajid.v35i1.159] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Accepted: 04/22/2020] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Suspected diarrhoeal-illness outbreaks affecting mostly children < 5 years were investigated between May and July 2013 in Northern Cape province (NCP) and KwaZulu-Natal (KZN) province. This study describes the epidemiological, environmental and clinical characteristics and diarrhoeal-illnesses causative agent(s). METHODS A descriptive cross-sectional study was conducted. Cases were patients presenting at healthcare facilities with diarrhoeal-illness between 09 April and 09 July 2013 in NCP and 01 May and 31 July 2013 in KZN. Laboratory investigations were performed on stools and water samples using microscopy, culture and sensitivity screening and molecular assays. RESULTS A total of 953 cases including six deaths (case fatality rate [CFR]: 0.6%) were recorded in the Northern Cape province outbreak. Children < 5 years accounted for 58% of cases. Enteric viruses were detected in 51% of stools, with rotavirus detected in 43%. The predominant rotavirus strains were G3P[8] (45%) and G9P[8] (42%). Other enteric viruses were detected, with rotavirus co-infections (63%). No enteric pathogens detected in water specimens. KwaZulu-Natal outbreak: A total of 1749 cases including 26 deaths (CFR: 1.5%) were recorded. Children < 5 years accounted for 95% of cases. Rotavirus was detected in 55% of stools; other enteric viruses were detected, mostly as rotavirus co-infections. The predominant rotavirus strains were G2P[4] (54%) and G9P[8] (38%). CONCLUSION Although source(s) of the outbreaks were not identified, the diarrhoeal-illnesses were community-acquired. It is difficult to attribute the outbreaks to one causative agent(s) because of rotavirus co-infections with other enteric pathogens. While rotavirus was predominant, the outbreaks coincided with the annual rotavirus season.
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Affiliation(s)
- Andronica M Shonhiwa
- Division of Public Health Surveillance and Response, National Institute for Communicable Diseases, National Health Laboratory Service, Sandringham, Johannesburg, South Africa
| | - Genevie Ntshoe
- Division of Public Health Surveillance and Response, National Institute for Communicable Diseases, National Health Laboratory Service, Sandringham, Johannesburg, South Africa
- School of Health Systems and Public Health, Faculty of Health Science, University of Pretoria, Pretoria, South Africa
| | - Noreen Crisp
- Communicable Disease Control, Department of Health, Kimberley, South Africa
| | - Ayo J Olowolagba
- Communicable Disease Control, eThekwini Metropolitan Municipality Department of Health, Durban, South Africa
| | - Vusi Mbuthu
- Communicable Disease Control, eThekwini Metropolitan Municipality Department of Health, Durban, South Africa
| | - Maureen B Taylor
- School of Health Systems and Public Health, Faculty of Health Science, University of Pretoria, Pretoria, South Africa
- Department of Medical Virology, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
- National Health Laboratory Service, Tshwane Academic Division, Pretoria, South Africa
| | - Juno Thomas
- Centre for Enteric Diseases, National Institute for Communicable Diseases, National Health Laboratory Service, Sandringham, Johannesburg, South Africa
| | - Nicole A Page
- Department of Medical Virology, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
- Centre for Enteric Diseases, National Institute for Communicable Diseases, National Health Laboratory Service, Sandringham, Johannesburg, South Africa
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17
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Overview of the Development, Impacts, and Challenges of Live-Attenuated Oral Rotavirus Vaccines. Vaccines (Basel) 2020; 8:vaccines8030341. [PMID: 32604982 PMCID: PMC7565912 DOI: 10.3390/vaccines8030341] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 05/26/2020] [Accepted: 05/26/2020] [Indexed: 12/15/2022] Open
Abstract
Safety, efficacy, and cost-effectiveness are paramount to vaccine development. Following the isolation of rotavirus particles in 1969 and its evidence as an aetiology of severe dehydrating diarrhoea in infants and young children worldwide, the quest to find not only an acceptable and reliable but cost-effective vaccine has continued until now. Four live-attenuated oral rotavirus vaccines (LAORoVs) (Rotarix®, RotaTeq®, Rotavac®, and RotaSIIL®) have been developed and licensed to be used against all forms of rotavirus-associated infection. The efficacy of these vaccines is more obvious in the high-income countries (HIC) compared with the low- to middle-income countries (LMICs); however, the impact is far exceeding in the low-income countries (LICs). Despite the rotavirus vaccine efficacy and effectiveness, more than 90 countries (mostly Asia, America, and Europe) are yet to implement any of these vaccines. Implementation of these vaccines has continued to suffer a setback in these countries due to the vaccine cost, policy, discharging of strategic preventive measures, and infrastructures. This review reappraises the impacts and effectiveness of the current live-attenuated oral rotavirus vaccines from many representative countries of the globe. It examines the problems associated with the low efficacy of these vaccines and the way forward. Lastly, forefront efforts put forward to develop initial procedures for oral rotavirus vaccines were examined and re-connected to today vaccines.
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18
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Godfrey O, Zhang W, Amponsem-Boateng C, Bonney Oppong T, Zhao Q, Li D. Evidence of rotavirus vaccine impact in sub-Saharan Africa: Systematic review and meta-analysis. PLoS One 2020; 15:e0232113. [PMID: 32339187 PMCID: PMC7185587 DOI: 10.1371/journal.pone.0232113] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Accepted: 04/07/2020] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Over 34 countries in Africa have introduced rotavirus vaccine to their national immunization programs: monovalent (Rotarix®, RV1) and pentavalent (RotaTeq®, RV5) after South Africa introduced it in 2009. Since then several studies assessing the impact of the vaccine have been conducted. The principal aim of this study was to evaluate the impact of rotavirus vaccine in sub-Saharan Africa. METHODS A Literature search was performed using Mendeley, PubMed, ScienceDirect, grey literature and Web of Science databases of published studies from January 1, 2017, as years of recent publications on rotavirus vaccine impact in sub-Saharan Africa. A meta-analysis was conducted for rotavirus infection in children under 5 years using proportions of pre and post-vaccine introduction in these populations. Random-effect estimates were considered since the samples were from universal populations. RESULTS Out of the 935 articles identified, 17 studies met the inclusion for systematic review and meta-analysis. The pooled proportion for pre-vaccination period was 42%, 95% (CI: 38-46%), and reduced to 21%, 95% (CI: 17-25%) during post-vaccination period. Rotavirus diarrhea significantly reduced in children < 12 months as compared to children 12-24 months old. Seasonal peaks of rotavirus diarrhea were between June-September. However, data is limited to one year of post-vaccine introduction, and bias may present due to early vaccine impact. CONCLUSION We observed that the introduction of the rotavirus vaccine was partly responsible for the significant reduction in the burden of rotavirus-associated diarrhea in sub-Saharan Africa. Therefore, there is a need to encourage the remaining countries to introduce the vaccine to their routine national immunization programs.
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Affiliation(s)
- Opolot Godfrey
- Department of Epidemiology and Biostatistics, College of Public Health, Zhengzhou University, Zhengzhou, Henan, PR China
| | - Weidong Zhang
- Department of Epidemiology and Biostatistics, College of Public Health, Zhengzhou University, Zhengzhou, Henan, PR China
| | - Cecilia Amponsem-Boateng
- Department of Epidemiology and Biostatistics, College of Public Health, Zhengzhou University, Zhengzhou, Henan, PR China
| | - Timothy Bonney Oppong
- Department of Epidemiology and Biostatistics, College of Public Health, Zhengzhou University, Zhengzhou, Henan, PR China
| | - QingLin Zhao
- Department of Epidemiology and Biostatistics, College of Public Health, Zhengzhou University, Zhengzhou, Henan, PR China
| | - Dankang Li
- Department of Epidemiology and Biostatistics, College of Public Health, Zhengzhou University, Zhengzhou, Henan, PR China
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19
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The Burden of Acute Diarrheal Disease in Young Hospitalized Urban South African Children Five Years After Rotavirus Vaccine Introduction: A Retrospective Descriptive Study. Pediatr Infect Dis J 2019; 38:752-756. [PMID: 30985514 DOI: 10.1097/inf.0000000000002304] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Diarrheal disease is a leading cause of childhood morbidity and mortality worldwide. Multiple interventions, including rotavirus vaccination to infants since 2009, have reduced the incidence of diarrheal disease in South African children. Our study aimed to determine the burden of diarrheal disease 5 years after rotavirus vaccine introduction at a tertiary-level hospital. METHODS A retrospective review of a discharge summary database of children less than 5 years of age hospitalized with acute diarrheal illness from 2015 to 2016 at the Chris Hani Baragwanath Academic Hospital. RESULTS Diarrheal disease accounted for 14.8% of hospital admissions. The incidence (per 100,000 population) was 675.8 (95% CI: 638.8-714.3) in 2015 and 612.2 (95% CI: 577.0-648.9) in 2016. The case fatality ratio was 2.9% over the study period. The median age at diagnosis was 12 months (interquartile range: 6.2-21.4) and 50.4% of cases occurred during infancy. One third of cases were underweight and/or stunted. In a multivariable analysis using logistic regression, the adjusted odds ratio (aOR) for death was higher in children with an associated acute lower respiratory tract infection (aOR: 3.7, 95% CI: 1.2-11.5; P = 0.021), HIV infection (aOR: 9.1, 95% CI: 2.6-31.6; P = 0.001), and an age of less than 6 months (aOR: 6.9, 95% CI: 2.1-22.9; P = 0.002). CONCLUSIONS Sustained reductions in diarrheal disease incidence were observed 5 years post rotavirus vaccine implementation. In children hospitalized with an acute diarrheal illness, an increased risk of mortality occurs in young infants, children that are HIV infected, and those with an associated acute lower respiratory tract infection.
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20
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Asowata OE, Ashiru OT, Sturm AW, Moodley P. Stability of a monovalent rotavirus vaccine after exposure to different temperatures observed in KwaZulu-Natal, South Africa. Afr Health Sci 2019; 19:1993-1999. [PMID: 31656482 PMCID: PMC6794501 DOI: 10.4314/ahs.v19i2.22] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Rotavirus infection and its associated hospitalization of children less than 5 years old in middle- and low-income countries remains a public health challenge. We hypothesized that the Rotarix®potency is affected by non-optimal temperatures which translates into reduced vaccine effectiveness in these settings. OBJECTIVE To assess the effect of non-optimal temperatures on the potency of the Rotarix® vaccine in South Africa. METHODS Rotarix® vaccine was exposed to temperatures reflecting breaches in the cold chain. Vero cells (ATCC CCL-81) grown in a 24-well tissue culture plates were infected with Rotarix® vaccine viruses after exposure to non-optimal temperatures and the potency of the vaccine was determined using the plaque assay. RESULTS Exposure of the Rotarix® vaccine to seasonal temperatures in KwaZulu-Natal for 6 hours and to extreme temperatures of 40oC for 72 hours as well as to -20°C and -80°C for 12 hours did not affect the potency of the vaccine beyond its expected standard of >7 x 105 PFU/ml. CONCLUSION This study revealed that the Rotarix® vaccine remains potent even after exposure to non-optimal temperatures. However, this study only explored the effect of a constant 'adverse' temperature on vaccine potency and not the effect of temperature fluctuations.
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Affiliation(s)
- Osaretin Emmanuel Asowata
- Department of Medical Microbiology, Nelson R Mandela School of Medicine, University of KwaZulu-Natal
| | - Olubisi Titilayo Ashiru
- Department of Medical Microbiology, Nelson R Mandela School of Medicine, University of KwaZulu-Natal
| | - A Willem Sturm
- Department of Medical Microbiology, Nelson R Mandela School of Medicine, University of KwaZulu-Natal
| | - Prashini Moodley
- Department of Medical Microbiology, Nelson R Mandela School of Medicine, University of KwaZulu-Natal
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McAnerney JM, Cohen C, Cohen AL, Tempia S, Walaza S, Wong KK, Im J, Marks F, Dawood H, Panzner U, Keddy KH, Von Mollendorf C. Healthcare utilisation patterns for respiratory and gastrointestinal syndromes and meningitis in Msunduzi municipality, Pietermaritzburg, KwaZulu-Natal Province, South Africa, 2013. S Afr Med J 2019; 109:333-339. [PMID: 31131801 PMCID: PMC7804386 DOI: 10.7196/samj.2019.v109i5.13024] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Public health facilities are used by the majority of South Africans, and healthcare utilisation surveys have been a useful tool to estimate the burden of disease in a given area. OBJECTIVES To describe care-seeking behaviour in a periurban site with a high prevalence of HIV infection, as well as barriers to seeking appropriate healthcare. METHODS We conducted a cross-sectional household survey in 22 wards of the Msunduzi municipality in KwaZulu-Natal Province, South Africa, from October to December 2013 using a simple random sample of households selected from a 2011 census enumeration. A primary caregiver/adult decision-maker was interviewed regarding demographic data as well as health status and recent self-reported episodes of selected illnesses and healthcare utilisation. RESULTS Of the 2 238 eligible premises visited, 1 936 households (87%) with a total of 9 733 members were enrolled in the study. Of these, 635 (7%) reported one or more episodes of infectious illness during the study period. Public health clinics were most frequently consulted for all illnesses (361/635, 57%). Private healthcare (general practitioner, private clinic, private hospital) was sought by 90/635 of individuals (14%), only 13/635 (2%) reported seeking care from traditional healers, religious leaders or volunteers, and 71/635 (11%) did not seek any medical care for acute illnesses. Individuals in the lowest income group were more likely to seek care at public health facilities than those in the highest income group (70% v. 32%). CONCLUSIONS Public health facility-based surveillance may be representative of disease patterns in this community, although surveillance at household level shows that high-income individuals may be excluded because they were more likely to use private healthcare, and the proportion of individuals who died at home would have been missed by facility-based surveillance. Data obtained in such surveys may be useful for public health planning.
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Affiliation(s)
- J M McAnerney
- Centre for Respiratory Diseases and Meningitis, National Institute for Communicable Diseases of the National Health Laboratory Service, Johannesburg, South Africa.
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Steele A, Victor J, Carey M, Tate J, Atherly D, Pecenka C, Diaz Z, Parashar U, Kirkwood C. Experiences with rotavirus vaccines: can we improve rotavirus vaccine impact in developing countries? Hum Vaccin Immunother 2019; 15:1215-1227. [PMID: 30735087 PMCID: PMC6663148 DOI: 10.1080/21645515.2018.1553593] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2018] [Revised: 11/06/2018] [Accepted: 11/22/2018] [Indexed: 12/16/2022] Open
Abstract
Rotavirus vaccines have been introduced into over 95 countries globally and demonstrate substantial impact in reducing diarrheal mortality and diarrheal hospitalizations in young children. The vaccines are also considered by WHO as "very cost effective" interventions for young children, particularly in countries with high diarrheal disease burden. Yet the full potential impact of rotavirus immunization is yet to be realized. Large countries with big birth cohorts and where disease burden is high in Africa and Asia have not yet implemented rotavirus vaccines at all or at scale. Significant advances have been made demonstrating the impact of the vaccines in low- and lower-middle income countries, yet the modest effectiveness of the vaccines in these settings is challenging. Current research highlights these challenges and considers alternative strategies to overcome them, including alternative immunization schedules and host factors that may inform us of new opportunities.
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Affiliation(s)
- A.D. Steele
- Enteric and Diarrheal Diseases, Bill & Melinda Gates Foundation, Seattle, WA, USA
| | - J.C. Victor
- Policy, Access and Innovation, Center for Vaccine Innovation and Access, Seattle, WA, USA
| | - M.E. Carey
- Enteric and Diarrheal Diseases, Bill & Melinda Gates Foundation, Seattle, WA, USA
| | - J.E. Tate
- Division of Viral Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - D.E. Atherly
- Policy, Access and Innovation, Center for Vaccine Innovation and Access, Seattle, WA, USA
| | - C. Pecenka
- Policy, Access and Innovation, Center for Vaccine Innovation and Access, Seattle, WA, USA
| | - Z. Diaz
- Enteric and Diarrheal Diseases, Bill & Melinda Gates Foundation, Seattle, WA, USA
| | - U.D. Parashar
- Division of Viral Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - C.D. Kirkwood
- Enteric and Diarrheal Diseases, Bill & Melinda Gates Foundation, Seattle, WA, USA
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23
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Asowata OE, Ashiru OT, Mahomed S, Sturm AW, Moodley P. Influence of vaccination status and clinical, seasonal and sociodemographic factors on rotavirus prevalence in KwaZulu-Natal, South Africa. S Afr J Infect Dis 2018. [DOI: 10.1080/23120053.2018.1551850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Affiliation(s)
- Osaretin E Asowata
- Department of Medical Microbiology, University of KwaZulu-Natal, Durban, South Africa
| | - Olubisi T Ashiru
- Department of Medical Microbiology, University of KwaZulu-Natal, Durban, South Africa
| | - Saajida Mahomed
- Department of Medical Microbiology, University of KwaZulu-Natal, Durban, South Africa
| | - A Willem Sturm
- Department of Medical Microbiology, University of KwaZulu-Natal, Durban, South Africa
| | - Prashini Moodley
- Department of Medical Microbiology, University of KwaZulu-Natal, Durban, South Africa
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24
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Simwaka JC, Mpabalwani EM, Seheri M, Peenze I, Monze M, Matapo B, Parashar UD, Mufunda J, Mphahlele JM, Tate JE, Mwenda JM. Diversity of rotavirus strains circulating in children under five years of age who presented with acute gastroenteritis before and after rotavirus vaccine introduction, University Teaching Hospital, Lusaka, Zambia, 2008-2015. Vaccine 2018; 36:7243-7247. [PMID: 29907481 PMCID: PMC11973881 DOI: 10.1016/j.vaccine.2018.03.035] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Revised: 12/16/2017] [Accepted: 03/14/2018] [Indexed: 01/15/2023]
Abstract
BACKGROUND Following the introduction of rotavirus vaccine into the routine immunization schedule, the burden of rotavirus disease has significantly reduced in Zambia. Although rotavirus vaccines appear to confer good cross-protection against both vaccine and non-vaccine strains, concerns about strain replacement following vaccine implementation remain. We describe the diversity of the circulating rotavirus strains before and after the Rotarix® vaccine was introduced in Lusaka from January 2012. METHODS Under five children were enrolled through active surveillance at University Teaching Hospital using a standardized WHO case investigation form. Stool samples were collected from children who presented with ≥3 loose stool in 24 h and were admitted to the hospital for acute gastroenteritis as a primary illness. Samples were tested for group A rotavirus antigen enzyme-linked immunosorbent assay. Randomly selected rotavirus positive samples were analysed by reverse transcription polymerase chain reaction for G and P genotyping and and Nucleotide sequencing was used to confirm some mixed infections. RESULTS A total of 4150 cases were enrolled and stool samples were collected from 4066 (98%) children between 2008 and 2011, before the vaccine was introduced. Rotavirus antigen was detected in 1561/4066 (38%). After vaccine introduction (2012 to 2015), 3168 cases were enrolled, 3092 (98%) samples were collected, and 977/3092 (32%) were positive for rotavirus. The most common G and P genotype combinations before vaccine introduction were G1P[8] (49%) in 2008; G12P[6] (24%) and G9P[8] (22%) in 2009; mixed rotavirus infections (32%) and G9P[8] (20%) in 2010, and G1P[6] (46%), G9P[6] (16%) and mixed infections (20%) in 2011. The predominant strains after vaccine introduction were G1P[8] (25%), G2P[4] (28%) and G2P[6] (23%) in 2012; G2P[4] (36%) and G2P[6] (44%) in 2013; G1P[8] (43%), G2P[4] (9%), and G2P[6] (24%) in 2014, while G2P[4] (54%) and G2P[6] (20%) continued to circulate in 2015. CONCLUSION These continual changes in the predominant strains suggest natural secular variation in circulating rotavirus strains post-vaccine introduction. These findings highlight the need for ongoing surveillance to continue monitoring how vaccine use affects strain evolution over a longer period of time and assess any normal seasonal fluctuations of the rotavirus strains.
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Affiliation(s)
- J C Simwaka
- University Teaching Hospital, Department of Pathology & Microbiology, Virology Laboratory, Lusaka, Zambia.
| | - Evans M Mpabalwani
- University Teaching Hospital, Department of Pediatrics' and Child Health, Lusaka, Zambia
| | - Mapaseka Seheri
- Sefako Makgatho Health Sciences University, South African Medical Research Council Diarrhoeal Pathogens Research Unit and WHO AFRO Rotavirus Regional Reference Laboratory, Department of Virology, Medunsa, Pretoria, South Africa
| | - Ina Peenze
- Sefako Makgatho Health Sciences University, South African Medical Research Council Diarrhoeal Pathogens Research Unit and WHO AFRO Rotavirus Regional Reference Laboratory, Department of Virology, Medunsa, Pretoria, South Africa
| | - Mwaka Monze
- University Teaching Hospital, Department of Pathology & Microbiology, Virology Laboratory, Lusaka, Zambia
| | | | | | | | - Jeffrey M Mphahlele
- Sefako Makgatho Health Sciences University, South African Medical Research Council Diarrhoeal Pathogens Research Unit and WHO AFRO Rotavirus Regional Reference Laboratory, Department of Virology, Medunsa, Pretoria, South Africa
| | | | - Jason M Mwenda
- World Health Organization Regional office for Africa (WHO/AFRO), Brazzaville, Congo
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Jani B, Hokororo A, Mchomvu J, Cortese MM, Kamugisha C, Mujuni D, Kallovya D, Parashar UD, Mwenda JM, Lyimo D, Materu A, Omari KF, Waziri M, Laswai T, Juma H, Mlay J, Dogani J, Stephen E, Seugendo M, Nkumbi U, Lyakurwa A, Matojo A, Bendera E, Senyota J, Msingwa V, Fungo Y, Michael F, Mpamba A, Chambo A, Cholobi H, Lyamuya F, Chami I, Mchome E, Mshana AM, Mushi E, Mariki U, Chard R, Tuju D, Ambokile N, Lukwale F, Kyessi F, Khamis A, Michael I, Macha D, Saguti A. Detection of rotavirus before and after monovalent rotavirus vaccine introduction and vaccine effectiveness among children in mainland Tanzania. Vaccine 2018; 36:7149-7156. [PMID: 29655631 DOI: 10.1016/j.vaccine.2018.01.071] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Revised: 01/06/2018] [Accepted: 01/29/2018] [Indexed: 10/17/2022]
Abstract
BACKGROUND Monovalent rotavirus vaccine (RV1) was introduced in Tanzania in January 2013 under the Reach Every Child initiative, to be given at ages 6 and 10 weeks. We used the sentinel hospital rotavirus surveillance system to examine the rotavirus detection rate before and after vaccine introduction and estimate vaccine effectiveness. METHODS Before vaccine introduction, rotavirus surveillance was established at two mainland hospitals; children admitted for acute diarrhea were eligible for enrollment and stools were tested for rotavirus antigen. We compared the rotavirus positivity rate in the pre-vaccine period (Tanga Hospital, 2009 and 2011; Bugando Medical Centre, 2012) to that from post-introduction years, 2014-2015. In 2013, surveillance was established at 9 additional hospitals. We examined rotavirus positivity among infants at these sites for 2014-2015. We obtained vaccine records and calculated vaccine effectiveness at 3 sites using case-test-negative control design. RESULTS At Tanga Hospital, the rotavirus positivity rate among infants was 41% (102/251) pre-vaccine and 14% (28/197) in post-vaccine years (rate ratio: 0.35 [95% CI 0.22-0.54]). At Bugando, the positivity rate was 58% (83/143) pre-vaccine, and 18% (49/277) post-introduction (rate ratio 0.30 [95% CI 0.210.44]). Results were similar among children <5 years. At the new sites, the median site rotavirus positivity rate among infants was 26% in 2014 (range 19-44%) and 18% in 2015 (range 16-33%). The effectiveness of ≥1 RV1 dose against rotavirus hospitalization among children 5-23 months was 53% (95% CI: -14, 81), and 66% (95% CI: 9-87) against hospitalization with intravenous rehydration. Following introduction, peak rotavirus activity occurred later in the year and appeared more concentrated in time. CONCLUSION Rotavirus surveillance data from Tanzania indicate that the rotavirus positivity rate among children hospitalized with diarrhea that were enrolled was substantially reduced after vaccine introduction. Low positivity rates among infants were detected at hospitals across the country. Overall, the data support that rotavirus vaccine has been successfully introduced and is effective in Tanzanian children.
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Affiliation(s)
- Bhavin Jani
- World Health Organization, Country Office, Dar Es Salaam, Tanzania
| | - Adolfine Hokororo
- Bugando Medical Center/Catholic University of Health and Allied Science, Mwanza, Tanzania
| | | | - Margaret M Cortese
- Divison of Viral Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA.
| | | | - Delphinius Mujuni
- Ministry of Health Community Development, Gender, Elderly and Children, Dar Es Salaam, Tanzania
| | - Dotto Kallovya
- National Health Laboratory Quality Assurance Training Centre, Dar Es Salaam, Tanzania
| | - Umesh D Parashar
- Divison of Viral Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Jason M Mwenda
- Regional Office for AFRICA (WHO/AFRO), Brazzaville, Republic of Congo
| | - DaFrossa Lyimo
- Ministry of Health Community Development, Gender, Elderly and Children, Dar Es Salaam, Tanzania
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Tsolenyanu E, Djadou KE, Fiawoo M, Akolly DAE, Mwenda JM, Leshem E, Tate JE, Aliabadi N, Koudema W, Guedenon KM, Godonou M, Dagnra A, Gbadoe AD, Boko A, Landoh D, Atakouma Y, Parashar UD. Evidence of the impact of monovalent rotavirus vaccine on childhood acute gastroenteritis hospitalization in Togo. Vaccine 2018; 36:7185-7191. [PMID: 29397224 PMCID: PMC11973829 DOI: 10.1016/j.vaccine.2018.01.058] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Revised: 11/23/2017] [Accepted: 01/22/2018] [Indexed: 11/19/2022]
Abstract
BACKGROUND Monovalent rotavirus vaccine (RV1) was introduced in the immunization schedule of Togo in June 2014. We evaluated the impact of rotavirus vaccines on acute gastroenteritis (AGE) and rotavirus-associated hospitalizations in Togolese children. METHODS Sentinel surveillance for AGE (defined as ≥3 liquid or semi-liquid stools/24 h lasting <7 days) hospitalizations among children <5 years of age was conducted in two sites in the capital city, Lome. ELISA was used for diagnosis of rotavirus infection in children with AGE. Additionally, review of hospitalization registers was performed at five hospitals to assess trends in AGE hospitalizations among children aged <5 years. For the vaccine impact assessment, pre-rotavirus vaccine introduction (July 2010-June 2014) and post-rotavirus vaccine introduction (July 2014-June 2016) periods were compared for annual changes in proportions of hospitalizations associated with AGE and rotavirus. RESULTS During the pre-vaccine period, sentinel surveillance showed that 1017 patients were enrolled and 57% (range, 53-62%) tested positive for rotavirus, declining to 42% (23% reduction) in the first post-vaccine year and to 26% (53% reduction) in the second post-vaccine year; declines were most marked among infants. The patient register review showed that, compared with pre-vaccine rotavirus seasons, declines in hospitalizations due to all-cause AGE during post-vaccine rotavirus seasons were 48% among <1 year age-group in both first and second years following vaccine introduction. Among 1-4 year olds no reduction was noted in the first year and a 19% decline occurred in the second year. CONCLUSIONS We report rapid and marked reduction in the number of AGE hospitalizations and the proportion of AGE hospitalizations attributable to rotavirus in the first two years post- RV1 implementation in Togo. It is necessary to monitor long-term vaccine impact on rotavirus disease burden through continued surveillance.
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Affiliation(s)
| | | | | | | | - Jason M Mwenda
- The World Health Organization, Regional Office for Africa, Brazzaville, Congo.
| | - Eyal Leshem
- National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, USA
| | - Jacqueline E Tate
- National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, USA
| | - Negar Aliabadi
- National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, USA
| | | | | | | | | | | | | | | | - Yawo Atakouma
- Department of Paediatrics, Medical School of Lome, Togo
| | - Umesh D Parashar
- National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, USA
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27
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Lyamuya F, Michael F, Jani B, Fungo Y, Chambo A, Chami I, Bulali R, Mpamba A, Cholobi H, Kallovya D, Kamugisha C, Mwenda JM, Cortese MM. Trends in diarrhea hospitalizations among infants at three hospitals in Tanzania before and after rotavirus vaccine introduction. Vaccine 2018; 36:7157-7164. [PMID: 29655628 DOI: 10.1016/j.vaccine.2017.11.051] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2017] [Revised: 11/06/2017] [Accepted: 11/15/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND The Tanzania Ministry of Health introduced monovalent human rotavirus vaccine in January 2013, to be administered at ages 6 and 10 weeks. Data suggest there was high vaccine uptake. We used hospital ward registers from 3 hospitals to examine trends in diarrhea hospitalizations among infants before and after vaccine introduction. METHODS Ward registers from Dodoma Regional Referral Hospital (Central Tanzania), and two hospitals in Mbeya (Southwest area), Mbeya Zonal Referral Hospital and Mbalizi Hospital, were used to tally admissions for diarrhea among children by age group, month and year. Rotavirus surveillance had started at these hospitals in early 2013; the proportion of infants enrolled and rotavirus-EIA positive were examined by month to determine peak periods of rotavirus disease post-vaccine introduction. RESULTS Registers were available for 2-4 prevaccine years and 2-3 post introduction years. At Dodoma Regional Referral Hospital, compared with the mean of 2011 and 2012, diarrhea hospitalizations among infants were 26% lower in 2015 and 58% lower in 2016. The diarrhea peak shifted later in the year first by 1 and then by 2-3 months from prevaccine. At the Mbeya hospitals, the number of diarrhea admissions in prevaccine period varied substantially by year. At Mbeya Referral Hospital, diarrhea hospitalizations among infants were lower by 25-37% in 2014 and 11-26% in 2015, while at Mbalizi Hospital, these hospitalizations were 4% lower in 2014 and 14% higher in 2015. Rotavirus testing data demonstrated a lowering of the prevaccine peak, a shift in timing of the peak months and indicated that other diarrheal peaks in post-introduction years were not due to rotavirus. CONCLUSIONS In this ecological evaluation, total diarrhea hospitalizations among infants were lower (≥25% lower in ≥1 year) following introduction in 2 of 3 hospitals. There are challenges in using ward registers to ascertain possible impact of rotavirus vaccine introduction on trends in hospitalizations for treatment of all diarrheal illness.
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Affiliation(s)
| | | | - Bhavin Jani
- World Health Organization, Country Office, Dar es Salaam, Tanzania
| | | | | | | | | | | | | | - Dotto Kallovya
- National Health Laboratory Quality Assurance Training Centre, Dar es Salaam, Tanzania
| | | | - Jason M Mwenda
- World Health Organization, AFRO Office, Brazzaville, Congo
| | - Margaret M Cortese
- Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA.
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Muendo C, Laving A, Kumar R, Osano B, Egondi T, Njuguna P. Prevalence of rotavirus infection among children with acute diarrhoea after rotavirus vaccine introduction in Kenya, a hospital cross-sectional study. BMC Pediatr 2018; 18:323. [PMID: 30309343 PMCID: PMC6180366 DOI: 10.1186/s12887-018-1291-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Accepted: 09/26/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Rotavirus infection is the most common cause of acute gastroenteritis globally in children under 5 years of age and is responsible for approximately 5% of all child deaths yearly. Rotavirus vaccination is considered an effective public health strategy to prevent infection and reduce the severity of disease. Multi-centre country trials on rotavirus vaccines demonstrated efficacy rates of more than 85% in developed countries but only about 65% in developing nations. Rotavirus vaccination was introduced into the Kenya Expanded Programme on Immunization (KEPI) in 2014. The objective of our study was to determine the prevalence of rotavirus infection, severity of acute diarrhoea and to determine the rotavirus vaccination status among children aged 3-24 months presenting with acute diarrhoea at Kenyatta National Hospital after introduction of rotavirus vaccine in Kenya. METHODS A total of 365 children aged 3-24 months presenting with acute diarrhoea at KNH were recruited from August 2016 to April 2017. Data on rotavirus vaccination status, nutritional status, feeding practices and sociodemographic characteristics were obtained and a full clinical evaluation of the patients was done. Severity of the gastroenteritis was assessed using the 20 point Vesikari Clinical Severity Scoring System. The children who were admitted were followed up for 7 days using hospital ward registers. Comorbid conditions were established from patient's clinical records and physical examination. Stool specimens from study participants were tested for rotavirus using a commercially available enzyme linked immunosorbent immunoassay kit- ProSpecT Rotavirus Microplate Assay. RESULTS Majority of the children (96.7%) had received rotavirus vaccinations. The overall rotavirus prevalence was 14.5% and was higher among 17-24 months at 19.5%. The prevalence somewhat differed by gender, nutritional status, exclusive breastfeeding status, age and education level of mother/caregiver. Overall, a half of the children had severe acute diarrhoea and there were some differences in severity by child/mother characteristics. CONCLUSION There is still burden of rotavirus diarrhoea after introduction of rotavirus vaccine and the prevalence varies by child characteristics.
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Affiliation(s)
| | - Ahmed Laving
- Department of Paediatrics and Child Health, University of Nairobi, P.O. Box 19676–00202, Nairobi, Kenya
| | - Rashmi Kumar
- Department of Paediatrics and Child Health, University of Nairobi, P.O. Box 19676–00202, Nairobi, Kenya
| | - Boniface Osano
- Department of Paediatrics and Child Health, University of Nairobi, P.O. Box 19676–00202, Nairobi, Kenya
| | - Thaddaeus Egondi
- Drugs for Neglected Diseases initiative, P.O. Box 21936–00505, Nairobi, Kenya
| | - Pamela Njuguna
- Public Health Specialist, Afya Resource Associates, P. O. Box 238–00202, Nairobi, Kenya
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Nadan S, Taylor MB, Groome MJ, Cohen C, Madhi SA, Page NA. Epidemiology of human astroviruses among children younger than 5 years: Prospective hospital-based sentinel surveillance in South Africa, 2009-2014. J Med Virol 2018; 91:225-234. [PMID: 30192398 DOI: 10.1002/jmv.25308] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Revised: 07/02/2018] [Accepted: 09/02/2018] [Indexed: 01/07/2023]
Abstract
BACKGROUND The epidemiology of human astroviruses (HAstVs) in hospitalised patients less than 5 years of age from selected sites in South Africa was investigated. Diarrheagenic stool specimens collected from April 2009 to May 2014 were screened retrospectively for selected viruses, bacteria and parasites. METHOD Patient data were analysed to identify epidemiologic factors most frequently detected with HAstV infections. The following case-comparisons were investigated; HAstV-positive and HAstV-negative children, human immunodeficiency virus (HIV)-infected and HIV-uninfected (HAstV-positive) children and HIV-exposed and unexposed (HAstV-positive HIV-uninfected) children. RESULTS Astrovirus was identified in 7.0% (234/3340) of cases and most frequently in ages 7 to 12 months (9.2%; 90/975) compared with 5.8% to 6.6% in other 6-month age groups. No seasonal trends were observed. More HAstVs were detected in children from homes that used outdoor water sources (7.6%) compared to indoor sources [5.7%; adjusted odds ratio (aOR), 1.5; 95% CI, 1.1-2.1; P = 0.009]. Astroviruses were detected in 8.4% (67/799) of HIV-uninfected patients that were exposed to HIV compared with 5.9% (74/1257) of HIV-unexposed patients ( P = 0.032). CONCLUSION Astroviruses were most prevalent in children aged 7 to 12 months and were detected throughout the study period. The study was limited as only hospitalised patients were investigated and no comparisons were made to diarrhoea-free control groups. Future HAstV surveillance should include community-based studies and children presenting at outpatient facilities.
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Affiliation(s)
- Sandrama Nadan
- Centre for Enteric Diseases, Virology Division, National Institute for Communicable Disease, Sandringham, South Africa.,Department of Medical Virology, Faculty of Health Sciences, University of Pretoria, Arcadia, South Africa
| | - Maureen B Taylor
- Department of Medical Virology, Faculty of Health Sciences, University of Pretoria, Arcadia, South Africa
| | - Michelle J Groome
- Department of Science and Technology/National Research Foundation: Vaccine Preventable Diseases, University of the Witwatersrand, Johannesburg, South Africa.,Medical Research Council: Respiratory and Meningeal Pathogens Research Unit, University of the Witwatersrand, Johannesburg, South Africa
| | - Cheryl Cohen
- Centre for Respiratory Diseases and Meningitis, Epidemiology Division, National Institute for Communicable Disease, Sandringham, South Africa
| | - Shabir A Madhi
- Department of Science and Technology/National Research Foundation: Vaccine Preventable Diseases, University of the Witwatersrand, Johannesburg, South Africa.,Medical Research Council: Respiratory and Meningeal Pathogens Research Unit, University of the Witwatersrand, Johannesburg, South Africa
| | - Nicola A Page
- Centre for Enteric Diseases, Virology Division, National Institute for Communicable Disease, Sandringham, South Africa.,Department of Medical Virology, Faculty of Health Sciences, University of Pretoria, Arcadia, South Africa
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30
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Sanneh B, Papa Sey A, Shah M, Tate J, Sonko M, Jagne S, Jarju M, Sowe D, Taal M, Cohen A, Parashar U, Mwenda JM. Impact of pentavalent rotavirus vaccine against severe rotavirus diarrhoea in The Gambia. Vaccine 2018; 36:7179-7184. [PMID: 29544688 DOI: 10.1016/j.vaccine.2018.02.091] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Revised: 02/05/2018] [Accepted: 02/22/2018] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Rotavirus vaccines protect against the leading cause of severe childhood diarrhoea, and have been introduced in many low-income African countries. The Gambia introducedRotateq® (RV5) into their national immunization program in 2013. We revieweddata from an active rotavirus sentinel surveillancesitefor early evidence of vaccine impact. METHODS We compared rotavirus prevalence in diarrhoeal stool in children< 5 years of age admittedat the Edward Francis Small Teaching Hospital sentinel surveillance site before (2013) andafterRV5 introduction (2015-2016) in the Gambia. The rotavirus-percent positive was separately compared for all diarrhoealhospitalizations and for hospitalizations with severe symptoms. Rotavirus prevalence was compared annually for the pre-vaccine year of 2013 with post-vaccine years of 2015 and 2016 using chi-square or Fisher's exact tests and the p-value to establish significant relationship was set at p < 0.05. All analyses were completed in SAS 9.3 (SAS Analytics, North Carolina). RESULTS Rotavirus prevalence among all diarrhoeahospitalizations decreased from 22% in 2013 to 11% in 2015 (p = 0.04), while remaining unchanged in 2016 (18%, p = 0.56). For hospitalizations that were clinically severe and/or treated with intravenous fluids (mean of 46 per year), the rotavirus prevalence decreased from 33% in 2013 to 8% in 2015 (p = 0.04), and to 15% in 2016 (p = 0.08). The children with age <1 year accounted for 45% the population infected with rotavirus in both pre and post rotavirus vaccination periods. CONCLUSIONS Rotavirus vaccine introduction in the Gambia could be among factors resulting in decreased diarrhea hospitalizations among children at the Edward Francis Small Teaching Hospital, particularly those with severe disease. These results support the continuation of rotavirus vaccine and additional monitoring of rotavirus hospitalization trends in the country.
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Affiliation(s)
- Bakary Sanneh
- National Public Health Laboratories, Ministry of Health and Social Welfare, Kotu Layout, Kotu, Gambia.
| | - Alhagie Papa Sey
- National Public Health Laboratories, Ministry of Health and Social Welfare, Kotu Layout, Kotu, Gambia
| | - Minesh Shah
- Division of Viral Diseases, Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Jacqueline Tate
- Division of Viral Diseases, Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Mariama Sonko
- Edward Francis Small Teaching Hospital, Ministry of Health and Social Welfare, Banjul, Gambia
| | - Sheriffo Jagne
- National Public Health Laboratories, Ministry of Health and Social Welfare, Kotu Layout, Kotu, Gambia; University of Noguchi, Ghana
| | - ModouLamin Jarju
- National Public Health Laboratories, Ministry of Health and Social Welfare, Kotu Layout, Kotu, Gambia
| | - Dawda Sowe
- ExpandedProgrammes in Immunization, Ministry of Health and Social Welfare, Kotu Layout, Kotu, Gambia
| | - Makie Taal
- Ministry of Health and Social Welfare, Banjul, Gambia
| | - Adam Cohen
- World Health Organization, Geneva, Switzerland
| | - Umesh Parashar
- Division of Viral Diseases, Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Jason M Mwenda
- World Health Organization, Regional Office for Africa, Immunization, Vaccines and Emergencies (IVE) Cluster, Brazzaville, Congo
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Wandera EA, Mohammad S, Bundi M, Nyangao J, Galata A, Kathiiko C, Odoyo E, Guyo S, Miring'u G, Komoto S, Ichinose Y. Impact of rotavirus vaccination on rotavirus hospitalisation rates among a resource-limited rural population in Mbita, Western Kenya. Trop Med Int Health 2018; 23:425-432. [PMID: 29432666 DOI: 10.1111/tmi.13040] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
OBJECTIVES A two-dose oral monovalent rotavirus vaccine (RV1) was introduced into the Kenyan National Immunization Program in July 2014. We assessed trends in hospitalisation for rotavirus-specific acute gastroenteritis (AGE) and strain distribution among children <5 years in a rural, resource-limited setting in Kenya before and after the nationwide implementation of the vaccine. METHODS Data on rotavirus AGE and strain distribution were derived from a 5-year hospital-based surveillance. We compared rotavirus-related hospitalisations and strain distribution in the 2-year post-vaccine period with the 3-year pre-vaccine baseline. Vaccine administrative data from the Unit of Vaccines and Immunization Services (UVIS) for Mbita sub-county were used to estimate rotavirus immunisation coverage in the study area. RESULTS We observed a 48% (95% CI: 27-64%) overall decline in rotavirus-related hospitalisations among children aged <5 years in the post-vaccine period. Coverage with the last dose of rotavirus vaccine increased from 51% in year 1% to 72% in year 2 of the vaccine implementation. Concurrently, reductions in rotavirus hospitalisations increased from 40% in the first year to 53% in the second year of vaccine use. The reductions were most pronounced among the vaccine-eligible group, with the proportion of cases in this age group dropping to 14% in post-vaccine years from a high of 51% in the pre-vaccine period. A diversity of rotavirus strains circulated before the introduction of the vaccine with G1P[8] being the most dominant strain. G2P[4] replaced G1P[8] as the dominant strain after the vaccine was introduced. CONCLUSIONS Rotavirus vaccination has resulted in a notable decline in hospital admissions for rotavirus infections in a rural resource-limited population in Kenya. This provides early evidence for continued use of rotavirus vaccines in routine childhood immunisations in Kenya. Our data also underscore the need for expanding coverage on second dose so as to maximise the impact of the vaccine.
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Affiliation(s)
- Ernest Apondi Wandera
- Institute of Tropical Medicine, Kenya Research Station, KEMRI/Nagasaki University, Nairobi, Kenya.,Graduate School of Biomedical Sciences, Nagasaki University, Nagasaki, Japan
| | - Shah Mohammad
- Institute of Tropical Medicine, Kenya Research Station, KEMRI/Nagasaki University, Nairobi, Kenya
| | - Martin Bundi
- Graduate School of Biomedical Sciences, Nagasaki University, Nagasaki, Japan.,National Biosafety Authority, Nairobi, Kenya
| | | | - Amina Galata
- Institute of Tropical Medicine, Kenya Research Station, KEMRI/Nagasaki University, Nairobi, Kenya
| | - Cyrus Kathiiko
- Institute of Tropical Medicine, Kenya Research Station, KEMRI/Nagasaki University, Nairobi, Kenya
| | - Erick Odoyo
- Institute of Tropical Medicine, Kenya Research Station, KEMRI/Nagasaki University, Nairobi, Kenya
| | - Sora Guyo
- Institute of Tropical Medicine, Kenya Research Station, KEMRI/Nagasaki University, Nairobi, Kenya
| | - Gabriel Miring'u
- Institute of Tropical Medicine, Kenya Research Station, KEMRI/Nagasaki University, Nairobi, Kenya
| | - Satoshi Komoto
- Department of Virology and Parasitology, School of Medicine, Fujita Health University, Toyoake, Japan
| | - Yoshio Ichinose
- Institute of Tropical Medicine, Kenya Research Station, KEMRI/Nagasaki University, Nairobi, Kenya.,Graduate School of Biomedical Sciences, Nagasaki University, Nagasaki, Japan
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Feleke H, Medhin G, Abebe A, Beyene B, Kloos H, Asrat D. Enteric pathogens and associated risk factors among under-five children with and without diarrhea in Wegera District, Northwestern Ethiopia. Pan Afr Med J 2018; 29:72. [PMID: 29875953 PMCID: PMC5987073 DOI: 10.11604/pamj.2018.29.72.13973] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Accepted: 01/12/2018] [Indexed: 11/30/2022] Open
Abstract
Introduction Childhood diarrhea is highly prevalent in slums in developing countries, but it remains understudied. The objectives of this study were to explore the prevalence of Giardia, rotavirus and bacterial enteropathogens among diarrheic and non-diarrheic children and investigate socio-environmental determinants of diarrhea in two Ethiopian towns. Methods A cross-sectional study was conducted from June to October 2016. Prevalence of childhood diarrhea was established using information gathered during interviews with mothers/guardians. Saline wet mounts of fresh stool samples were used to test for the presence of Giardia. Stool samples were cultured on MacConkey agar and suspected colonies were characterized using biochemical tests. Susceptibility testing was done by the disk diffusion method. ELISA was used to screen for rotavirus. Results A total of 225 children were included in this study. Four enteropathogens (Giardia, rotavirus, Shigella and Salmonella) were identified from 31% (35/112) diarrheic and 12% (14/113) from non-diarrheic children (p < 0.001). The prevalence of rotavirus infection was 18.0% among diarrheic children and 3.3% among non-diarrheic children unvaccinated against rotavirus (p < 0.01). The prevalence of Giardia was 21.0% among diarrheic and 8.0% among non-diarrheic children (p < 0.01). Diarrheic children had significantly higher rates of bloody stool (p < 0.02), vomiting, fever and breastfeeding for children beyond 23 months of age (p < 0.001). Giardia and rotavirus were identified in more diarrheic than non-diarrheic children. Conclusion The high prevalence of Giardia and rotavirus in the study area indicates the need for coordinated healthcare activities in the two communities. Vaccination against rotavirus infections and educational interventions are recommended.
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Affiliation(s)
- Hailemariam Feleke
- Ethiopian Institute of Water Resources, Addis Ababa University, Ethiopia.,Department of Biology, Assosa University, Ethiopia
| | - Girmay Medhin
- Aklilu Lemma Institute of Pathobiology, Addis Ababa University, Ethiopia
| | | | | | - Helmut Kloos
- Medical Center, University of California, San Francisco, USA
| | - Daniel Asrat
- Faculty of Medicine, Addis Ababa University, Ethiopia
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Abstract
PURPOSE OF REVIEW Rotavirus vaccines are playing a pivotal role in improving lives of infants and young children in low and middle-income countries (LMICs). Many of these countries have adopted the vaccine into their routine immunization, whereas others are considering introduction. This article provides an update on the impact of rotavirus vaccines in LMICs on morbidity and mortality in children aged less than 5 years, and their cost-effectiveness. RECENT FINDINGS The WHO, in 2013, updated its recommendation to prioritize introduction of rotavirus vaccines in the routine immunization schedule, without age restrictions. Despite the decreased efficacy of the vaccines in LMICs, data from Sub-Saharan Africa have demonstrated a decrease in rotavirus-related morbidity, with some sites reporting an indirect protective effect on children age ineligible to receive the vaccine. Even with improvements in sanitation, nutritional status in children, and other health-related indices in LMICs, the use of rotavirus vaccines will play an important role in preventing rotavirus-related gastroenteritis. Economic models predict a reduction in economic burden because of rotavirus-related health costs, making vaccine introduction cost-effective in resource-constrained settings. SUMMARY Increasing evidence from impact studies shows the significant impact of rotavirus vaccination on hospitalizations and economic burden because of rotavirus gastroenteritis in LMICs. Universal rotavirus vaccination is recommended, and introductions should be monitored by robust surveillance systems to measure effectiveness and impact.
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Page NA, Seheri LM, Groome MJ, Moyes J, Walaza S, Mphahlele J, Kahn K, Kapongo CN, Zar HJ, Tempia S, Cohen C, Madhi SA. Temporal association of rotavirus vaccination and genotype circulation in South Africa: Observations from 2002 to 2014. Vaccine 2017; 36:7231-7237. [PMID: 29110933 DOI: 10.1016/j.vaccine.2017.10.062] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Revised: 10/16/2017] [Accepted: 10/20/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND Rotavirus vaccination has reduced diarrhoeal morbidity and mortality globally. The monovalent rotavirus vaccine was introduced into the public immunization program in South Africa (SA) in 2009 and led to approximately 50% reduction in rotavirus hospitalization in young children. The aim of this study was to investigate the rotavirus genotype distribution in SA before and after vaccine introduction. MATERIALS AND METHODS In addition to pre-vaccine era surveillance conducted from 2002 to 2008 at Dr George Mukhari Hospital (DGM), rotavirus surveillance among children <5 years hospitalized for acute diarrhoea was established at seven sentinel sites in SA from April 2009 to December 2014. Stool specimens were screened by enzyme immunoassay and rotavirus positive specimens genotyped using standardised methods. RESULTS At DGM, there was a significant decrease in G1 strains from pre-vaccine introduction (34%; 479/1418; 2002-2009) compared to post-vaccine introduction (22%; 37/170; 2010-2014; p for trend <.001). Similarly, there was a significant increase in non-G1P[8] strains at this site (p for trend <.001). In expanded sentinel surveillance, when adjusted for age and site, the odds of rotavirus detection in hospitalized children with diarrhoea declined significantly from 2009 (46%; 423/917) to 2014 (22%; 205/939; p<.001). The odds of G1 detection declined significantly from 2009 (53%; 224/421) to 2010-2011 (26%; 183/703; aOR=0.5; p<.001) and 2012-2014 (9%; 80/905; aOR=0.1; p<.001). Non-G1P[8] strains showed a significant increase from 2009 (33%; 139/421) to 2012-2014 (52%; 473/905; aOR=2.5; p<.001). CONCLUSIONS Rotavirus vaccination of children was associated with temporal changes in circulating genotypes. Despite these temporal changes in circulating genotypes, the overall reduction in rotavirus disease in South Africa remains significant.
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Affiliation(s)
- N A Page
- National Institute for Communicable Diseases, National Health Laboratory Service, Johannesburg, South Africa; Department of Medical Virology, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa.
| | - L M Seheri
- South African Medical Research Council/Diarrhoeal Pathogens Research Unit, Sefako Makgatho Health Sciences University, Medunsa, South Africa
| | - M J Groome
- Medical Research Council: Respiratory and Meningeal Pathogens Research Unit, University of the Witwatersrand, Johannesburg, South Africa; Department of Science and Technology/National Research Foundation: Vaccine Preventable Diseases, University of Witwatersrand, Johannesburg, South Africa
| | - J Moyes
- National Institute for Communicable Diseases, National Health Laboratory Service, Johannesburg, South Africa
| | - S Walaza
- National Institute for Communicable Diseases, National Health Laboratory Service, Johannesburg, South Africa
| | - J Mphahlele
- South African Medical Research Council/Diarrhoeal Pathogens Research Unit, Sefako Makgatho Health Sciences University, Medunsa, South Africa
| | - K Kahn
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - C N Kapongo
- Department of Paediatrics, Ngwelezane Hospital, Empangeni, South Africa
| | - H J Zar
- Department of Paediatrics and Child Health/MRC Unit on Child & Adolescent Health, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa
| | - S Tempia
- Influenza Division, Centers for Disease Control and Prevention, Atlanta, GA, United States; Influenza Program, Centers for Disease Control and Prevention, Pretoria, South Africa; National Institute for Communicable Diseases, National Health Laboratory Service, Johannesburg, South Africa
| | - C Cohen
- National Institute for Communicable Diseases, National Health Laboratory Service, Johannesburg, South Africa
| | - S A Madhi
- National Institute for Communicable Diseases, National Health Laboratory Service, Johannesburg, South Africa; Medical Research Council: Respiratory and Meningeal Pathogens Research Unit, University of the Witwatersrand, Johannesburg, South Africa; Department of Science and Technology/National Research Foundation: Vaccine Preventable Diseases, University of Witwatersrand, Johannesburg, South Africa
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Rahajamanana VL, Raboba JL, Rakotozanany A, Razafindraibe NJ, Andriatahirintsoa EJPR, Razafindrakoto AC, Mioramalala SA, Razaiarimanga C, Weldegebriel GG, Burnett E, Mwenda JM, Seheri M, Mphahlele MJ, Robinson AL. Impact of rotavirus vaccine on all-cause diarrhea and rotavirus hospitalizations in Madagascar. Vaccine 2017; 36:7198-7204. [PMID: 28958809 DOI: 10.1016/j.vaccine.2017.08.091] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Revised: 08/09/2017] [Accepted: 08/16/2017] [Indexed: 11/15/2022]
Abstract
BACKGROUND Rotavirus vaccine was introduced into the Extended Program on Immunization in Madagascar in May 2014. We analyzed trends in prevalence of all cause diarrhea and rotavirus hospitalization in children <5years of age before and after vaccine introduction and assessed trend of circulating rotavirus genotypes at Centre Hospitalier Universitaire Mère Enfant Tsaralalàna (CHU MET). METHODS From January 2010 to December 2016, we reviewed the admission logbook to observe the rate of hospitalization caused by gastroenteritis among 19619 children <5years of age admitted at the hospital. In June 2013-December 2016, active rotavirus surveillance was also conducted at CHUMET with support from WHO. Rotavirus antigen was detected by EIA from stool specimen of children who are eligible for rotavirus gastroenteritis surveillance at sentinel site laboratory and rotavirus positive specimens were further genotyped at Regional Reference Laboratory by RT-PCR. RESULTS Diarrhea hospitalizations decreased after rotavirus vaccine introduction. The median proportion of annual hospitalizations due to diarrhea was 26% (range: 31-22%) before vaccine introduction; the proportion was 25% the year of vaccine introduction, 17% in 2015 and 16% in 2016. Rotavirus positivity paralleled patterns observed in diarrhea. Before vaccine introduction, 56% of stool specimens tested positive for rotavirus; the percent positive was 13% in 2015, 12% in 2016. Diverse genotypes were detected in the pre-vaccine period; the most common were G3P[8] (n=53; 66%), G2P[4] (n=12; 15%), and G1P[8] (n=11; 14%). 6 distinct genotypes were found in 2015; the most common genotype was G2P[4] (n=10; 67%), the remaining, 5, G12[P8], G3[P8], G1G3[P4], G3G12[P4][P8] and G1G3[NT] had one positive specimen each. CONCLUSIONS Following rotavirus vaccine introduction all-cause diarrhea and rotavirus-specific hospitalizations declined dramatically. The most common genotypes detected in the pre-vaccine period were G3P[8] and G2P[4] in 2015, the post vaccine period.
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Affiliation(s)
- V L Rahajamanana
- Department of Child Health, Teaching Hospital, Centre Hospitalier Universitaire Mère Enfant Tsaralàlana, Antananarivo, Madagascar.
| | - J L Raboba
- Department of Child Health, Teaching Hospital, Centre Hospitalier Universitaire Mère Enfant Tsaralàlana, Antananarivo, Madagascar
| | - A Rakotozanany
- Department of Child Health, Teaching Hospital, Centre Hospitalier Universitaire Mère Enfant Tsaralàlana, Antananarivo, Madagascar
| | - N J Razafindraibe
- Teaching Hospital, Centre Hospitalier Universitaire Andohatapenaka, Antananarivo, Madagascar
| | | | - A C Razafindrakoto
- Department of Child Health, Teaching Hospital, Centre Hospitalier Universitaire Mère Enfant Tsaralàlana, Antananarivo, Madagascar
| | - S A Mioramalala
- National Malaria Country Program, Public Health Ministry, Antananarivo, Madagascar
| | | | - G G Weldegebriel
- WHO Inter-Country Support Team: East and Southern Africa (WHO IST/ESA), Harare, Zimbabwe
| | - E Burnett
- Foundation for the Centers for Disease Control and Prevention, Division of Viral Diseases, Atlanta, USA
| | - J M Mwenda
- World Health Organization (WHO) Regional Office for Africa (WHO/AFRO), Brazzaville, Congo
| | - M Seheri
- Regional Rotavirus Reference Laboratory, SAMRC/Diarrheal Pathogens Research Unit, Department of Virology, Sefako Makgatho Health Sciences University, Pretoria, South Africa
| | - M J Mphahlele
- Regional Rotavirus Reference Laboratory, SAMRC/Diarrheal Pathogens Research Unit, Department of Virology, Sefako Makgatho Health Sciences University, Pretoria, South Africa
| | - A L Robinson
- Department of Child Health, Teaching Hospital, Centre Hospitalier Universitaire Mère Enfant Tsaralàlana, Antananarivo, Madagascar
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Wandera EA, Mohammad S, Bundi M, Komoto S, Nyangao J, Kathiiko C, Odoyo E, Miring'u G, Taniguchi K, Ichinose Y. Impact of rotavirus vaccination on rotavirus and all-cause gastroenteritis in peri-urban Kenyan children. Vaccine 2017; 35:5217-5223. [PMID: 28780116 DOI: 10.1016/j.vaccine.2017.07.096] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Revised: 07/24/2017] [Accepted: 07/26/2017] [Indexed: 12/25/2022]
Abstract
A monovalent rotavirus vaccine (RV1) was introduced into the National Immunization Program in Kenya in July 2014. We examined the impact of the vaccine on hospitalization for all-cause acute gastroenteritis (AGE) and rotavirus-specific AGE and strain distribution at a large referral hospital which serves a predominantly peri-urban population in Central Kenya. Data on rotavirus AGE and strain distribution were derived from ongoing hospital-based AGE surveillance. Hospital administrative data were used to compare trends in all-cause AGE. Pre-vaccine (July 2009-June 2014) and post-vaccine (July 2014-June 2016) periods were compared for changes in hospitalization for all-cause AGE and rotavirus AGE and strain distribution. Following the vaccine introduction, the proportion of children aged <5years hospitalized for rotavirus declined by 30% (95% CI: 19-45%) in the first year and 64% (95% CI: 49-77%) in the second year. Reductions in rotavirus positivity were most pronounced among the vaccine-eligible group (<12months) in the first year post-vaccination at 42% (95% CI: 28-56%). Greater reductions of 67% (95% CI: 51-79%) were seen in the second year in the 12-23months age group. Similarly, hospitalizations for all-cause AGE among children <5years of age decreased by 31% (95% CI: 24-40%) in the first year and 58% (95% CI: 49-67%) in the second year of vaccine introduction. Seasonal peaks of rotavirus and all-cause AGE were reduced substantially. There was an increased detection of G2P[4], G3P[6] and G3P[8], which coincided temporally with the timing of the vaccine introduction. Thus, introducing the rotavirus vaccine into the routine immunization program in Kenya has resulted in a notable decline in rotavirus and all-cause AGE hospitalizations in Central Kenya. This provides early evidence for public health policy makers in Kenya to support the sustained use of the rotavirus vaccine in routine immunizations.
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Affiliation(s)
- Ernest Apondi Wandera
- KEMRI/Nagasaki University, Institute of Tropical Medicine, Kenya Research Station, Nairobi, Kenya; Graduate School of Biomedical Sciences, Nagasaki University, Japan.
| | - Shah Mohammad
- KEMRI/Nagasaki University, Institute of Tropical Medicine, Kenya Research Station, Nairobi, Kenya
| | - Martin Bundi
- Graduate School of Biomedical Sciences, Nagasaki University, Japan; National Biosafety Authority, Nairobi, Kenya
| | - Satoshi Komoto
- Department of Virology and Parasitology, School of Medicine, Fujita Health University, Japan
| | | | - Cyrus Kathiiko
- KEMRI/Nagasaki University, Institute of Tropical Medicine, Kenya Research Station, Nairobi, Kenya
| | - Erick Odoyo
- KEMRI/Nagasaki University, Institute of Tropical Medicine, Kenya Research Station, Nairobi, Kenya
| | - Gabriel Miring'u
- KEMRI/Nagasaki University, Institute of Tropical Medicine, Kenya Research Station, Nairobi, Kenya
| | - Koki Taniguchi
- Department of Virology and Parasitology, School of Medicine, Fujita Health University, Japan
| | - Yoshio Ichinose
- KEMRI/Nagasaki University, Institute of Tropical Medicine, Kenya Research Station, Nairobi, Kenya; Graduate School of Biomedical Sciences, Nagasaki University, Japan
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Safety and immunogenicity of a live attenuated pentavalent rotavirus vaccine in HIV-exposed infants with or without HIV infection in Africa. AIDS 2017; 31:49-59. [PMID: 27662551 DOI: 10.1097/qad.0000000000001258] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE Although many HIV-infected (HIV+) and HIV-exposed but uninfected (HEU) infants have received live rotavirus vaccines since the WHO recommended universal administration of these vaccines to infants, there has been limited prospective information on their safety and immunogenicity in either group of infants. DESIGN/METHODS We performed a randomized, double-blinded, placebo-controlled trial of the safety and immunogenicity of oral pentavalent rotavirus vaccine (RV5) administered to HIV+ and HEU infants in four African countries. Ninety-three percent of HIV+ infants were receiving antiretroviral therapy prior to vaccination. Participants were followed for safety. Immune responses were measured 14 days after three doses of RV5, including serum antirotavirus neutralizing and IgA antibodies, IgA antibody in stool, and antirotavirus memory B and T-cell FluoroSpot. Shedding of RV5 in stool was monitored. RESULTS A total of 76 HIV+ and 126 HEU infants were enrolled from 2009 to 2013. No significant differences were found in adverse event rates, including grade 3 events, between RV5 and placebo recipients, for either HIV+ or HEU infants. The proportion of antirotavirus IgA responders (at least three-fold increase from baseline) after RV5 administration was 81% in both HIV+ and HEU infants, which was approximately 2.5-fold higher than in placebo recipients (P < 0.001). Neutralizing antibody responses to three of five serotypes were significantly higher after RV5 regardless of HIV status, and those of HIV+ infants were equal or greater than responses of HEU infants to all five serotypes. Only one HIV+ RV5 recipient had RV5 isolated from stool. CONCLUSION RV5 was immunogenic in both HIV+ and HEU infants and no safety signals were observed.
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Enane LA, Gastañaduy PA, Goldfarb DM, Pernica JM, Mokomane M, Moorad B, Masole L, Tate JE, Parashar UD, Steenhoff AP. Impact of Rotavirus Vaccination on Hospitalizations and Deaths From Childhood Gastroenteritis in Botswana. Clin Infect Dis 2016; 62 Suppl 2:S168-74. [PMID: 27059352 DOI: 10.1093/cid/civ1210] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND A monovalent human rotavirus vaccine (RV1) was introduced in Botswana in July 2012. We assessed the impact of RV1 vaccination on childhood gastroenteritis-related hospitalizations and deaths in 2013 and 2014. METHODS We obtained data from registers of 4 hospitals in Botswana on hospitalizations and deaths from gastroenteritis, regardless of cause, among children <5 years of age. Gastroenteritis hospitalizations and deaths during the prevaccine period (January 2009-December 2012) were compared to the postvaccine period (January 2013-December 2014). Vaccine coverage was estimated from data collected through a concurrent vaccine effectiveness study at the same hospitals. RESULTS By December 2014, coverage with ≥1 dose of RV1 was an estimated 90% among infants <1 year of age and 76% among children 12-23 months of age. In the prevaccine period, the annual median number of gastroenteritis-related hospitalizations in children <5 years of age was 1212, and of gastroenteritis-related deaths in children <2 years of age was 77. In the postvaccine period, gastroenteritis-related hospitalizations decreased by 23% (95% confidence interval [CI], 16%-29%) to 937, and gastroenteritis-related deaths decreased by 22% (95% CI, -9% to 44%) to 60. Declines were most prominent during the rotavirus season (May-October) and among infants <1 year of age, with reductions of 43% (95% CI, 34%-51%) in gastroenteritis hospitalizations and 48% (95% CI, 11%-69%) in gastroenteritis deaths. CONCLUSIONS Following introduction of RV1 into the national immunization program, significant declines in hospitalizations and deaths from gastroenteritis were observed among children in Botswana, suggestive of the beneficial public health impact of rotavirus vaccination.
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Affiliation(s)
- Leslie A Enane
- Division of Infectious Diseases, Department of Pediatrics, Children's Hospital of Philadelphia, Pennsylvania Botswana-UPenn Partnership, Gaborone, Botswana
| | - Paul A Gastañaduy
- Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - David M Goldfarb
- Botswana-UPenn Partnership, Gaborone, Botswana Division of Microbiology, Department of Pathology, University of British Columbia, Vancouver, Canada Department of Pediatrics, University of Botswana, Gaborone Division of Infectious Disease, Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
| | - Jeffrey M Pernica
- Botswana-UPenn Partnership, Gaborone, Botswana Division of Infectious Disease, Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
| | | | | | | | - Jacqueline E Tate
- Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Umesh D Parashar
- Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Andrew P Steenhoff
- Botswana-UPenn Partnership, Gaborone, Botswana Department of Pediatrics, University of Botswana, Gaborone Division of Infectious Diseases and Section of Global Health, Department of Pediatrics, Children's Hospital of Philadelphia and the University of Pennsylvania, Philadelphia
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Armah G, Pringle K, Enweronu-Laryea CC, Ansong D, Mwenda JM, Diamenu SK, Narh C, Lartey B, Binka F, Grytdal S, Patel M, Parashar U, Lopman B. Impact and Effectiveness of Monovalent Rotavirus Vaccine Against Severe Rotavirus Diarrhea in Ghana. Clin Infect Dis 2016; 62 Suppl 2:S200-7. [PMID: 27059357 DOI: 10.1093/cid/ciw014] [Citation(s) in RCA: 75] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Ghana was among the first African nations to introduce monovalent rotavirus vaccine (RV1) into its childhood immunization schedule in April 2012. We aimed to assess the impact of vaccine introduction on rotavirus and acute gastroenteritis (AGE) hospitalizations and to estimate vaccine effectiveness (VE). METHODS Using data from 2 teaching hospitals, monthly AGE and rotavirus admissions by age were examined 40 months before and 31 months after RV1 introduction using interrupted time-series analyses. From January 2013, we enrolled children <2 years of age who were eligible for RV1 from a total of 7 sentinel sites across the country. To estimate VE, we fit unconditional logistic regression models to calculate odds ratios of vaccination by rotavirus case-patient status, controlling for potential confounders. RESULTS Vaccine coverage ranged from 95% to 100% for dose 1 and 93% to 100% for dose 2. In the first 3 years after vaccine introduction, the percentage of hospital admissions positive for rotavirus fell from 48% in the prevaccine period to 28% (49% adjusted rate reduction; 95% confidence interval [CI], 32%-63%) postvaccination among <5-year-olds. With high vaccine coverage, it was not possible to arrive at robust VE estimates; any-dose VE against rotavirus hospitalization was estimated at 60% (95% CI, -2% to 84%;P= .056). CONCLUSIONS Results from the first 3 years following RV1 introduction suggest substantial reductions of pediatric diarrheal disease as a result of vaccination. Our VE estimate is consistent with the observed rotavirus decrease and with efficacy estimates from elsewhere in sub-Saharan Africa.
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Affiliation(s)
- George Armah
- Noguchi Memorial Institute for Medical Research, University of Ghana, Accra
| | | | | | | | - Jason M Mwenda
- World Health Organization Regional Office for Africa, Brazzaville, Republic of Congo
| | | | - Clement Narh
- Noguchi Memorial Institute for Medical Research, University of Ghana, Accra School of Public Health, University of Health and Allied Sciences, Hohoe, Ghana
| | - Belinda Lartey
- Noguchi Memorial Institute for Medical Research, University of Ghana, Accra
| | - Fred Binka
- School of Public Health, University of Health and Allied Sciences, Hohoe, Ghana
| | - Scott Grytdal
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Manish Patel
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Umesh Parashar
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Ben Lopman
- Centers for Disease Control and Prevention, Atlanta, Georgia
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Yen C, Healy K, Tate JE, Parashar UD, Bines J, Neuzil K, Santosham M, Steele AD. Rotavirus vaccination and intussusception - Science, surveillance, and safety: A review of evidence and recommendations for future research priorities in low and middle income countries. Hum Vaccin Immunother 2016; 12:2580-2589. [PMID: 27322835 PMCID: PMC5084992 DOI: 10.1080/21645515.2016.1197452] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Revised: 05/10/2016] [Accepted: 05/25/2016] [Indexed: 02/04/2023] Open
Abstract
As of January 2016, 80 countries have introduced rotavirus vaccines into their national immunization programs. Many have documented significant declines in rotavirus-specific and all-cause diarrheal illnesses following vaccine introduction. Two globally licensed rotavirus vaccines have been associated with a low risk of intussusception in several studies. In July 2014, the Rotavirus Organization of Technical Allies Council convened a meeting of research and advocacy organizations, public health experts, funders, and vaccine manufacturers to discuss post-marketing intussusception surveillance and rotavirus vaccine impact data. Meeting objectives were to evaluate updated data, identify and prioritize research gaps, discuss best practices for intussusception monitoring in lower-income settings and risk communication, and provide insight to country-level stakeholders on best practices for intussusception monitoring and communication. Meeting participants agreed with statements from expert bodies that the benefits of vaccination with currently available rotavirus vaccines outweigh the low risk of vaccination-associated intussusception. However, further research is needed to better understand the relationship of intussusception to wild-type rotavirus and rotavirus vaccines and delineate potential etiologies and mechanisms of intussusception. Additionally, evidence from research and post-licensure evaluations should be presented with evidence of the benefits of vaccination to best inform policymakers deciding on vaccine introduction or vaccination program sustainability.
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Affiliation(s)
- Catherine Yen
- Division of Viral Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Kelly Healy
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Jacqueline E. Tate
- Division of Viral Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Umesh D. Parashar
- Division of Viral Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Julie Bines
- Murdoch Childrens Research Institute, The University of Melbourne, Victoria, Australia
| | - Kathleen Neuzil
- University of Maryland School of Medicine, Baltimore, MD, USA
| | - Mathuram Santosham
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - A. Duncan Steele
- Enteric and Diarrhoeal Diseases, Global Health, Bill and Melinda Gates Foundation, Seattle, WA, USA
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Awotiwon OF, Pillay-van Wyk V, Dhansay A, Day C, Bradshaw D. Diarrhoea in children under five years of age in South Africa (1997-2014). Trop Med Int Health 2016; 21:1060-70. [PMID: 27314457 DOI: 10.1111/tmi.12739] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To present evidence from available reliable published data on the prevalence, incidence and severity of diarrhoea in children aged under five years in South Africa. METHODS We searched seven electronic databases. Two reviewers assessed the studies independently and extracted outcome data. The heterogeneity of the studies did not allow for a meta-analysis. RESULTS We found only one nationally representative study conducted in 1998 reporting a diarrhoea prevalence of 13% in children under five. Other studies were conducted in smaller settings across the country. Diarrhoea incidence was 10.13 per 1000 person years in children admitted to a tertiary hospital. Three studies reported severity of diarrhoea; however, they differed across study settings and time period. CONCLUSION The paucity of nationally representative prevalence data for SA necessitates more national surveys with standardised data-collection methods to allow for more effective comparisons.
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Affiliation(s)
- Oluwatoyin F Awotiwon
- Burden of Disease Research Unit, South African Medical Research Council, Tygerberg, South Africa
| | - Victoria Pillay-van Wyk
- Burden of Disease Research Unit, South African Medical Research Council, Tygerberg, South Africa
| | - Ali Dhansay
- Burden of Disease Research Unit, South African Medical Research Council, Tygerberg, South Africa.,Division of Human Nutrition, Faculty of Health Sciences, Stellenbosch University, Tygerberg, South Africa.,Department of Paediatrics and Child Health, Faculty of Health Sciences, Stellenbosch University, Tygerberg, South Africa
| | - Candy Day
- Health Systems Research Unit, Health Systems Trust, Westville, South Africa
| | - Debbie Bradshaw
- Burden of Disease Research Unit, South African Medical Research Council, Tygerberg, South Africa
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Groome MJ, Zell ER, Solomon F, Nzenze S, Parashar UD, Izu A, Madhi SA. Temporal Association of Rotavirus Vaccine Introduction and Reduction in All-Cause Childhood Diarrheal Hospitalizations in South Africa. Clin Infect Dis 2016; 62 Suppl 2:S188-95. [PMID: 27059355 PMCID: PMC11345717 DOI: 10.1093/cid/civ1204] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The public health impact of rotavirus vaccination in African settings with a high human immunodeficiency virus (HIV) infection prevalence is yet to be established. We evaluated trends in all-cause diarrheal hospitalizations in Soweto, Johannesburg, before and after the introduction of rotavirus vaccine into South Africa's national immunization program in August 2009. METHODS Hospitalizations in children <5 years of age with a diagnosis of diarrhea, defined byInternational Classification of Diseases, Tenth Revisioncodes A00-A05, A06.0-A06.3, A06.9, A07.0-A07.2, A07.9, and A08-A09, were identified at the Chris Hani Baragwanath Academic Hospital from 1 January 2006 to 31 December 2014. The median annual prevaccine (2006-2008) hospitalization incidence was compared to that of the vaccine era (2010-2014), and stratified by age group and HIV infection status. RESULTS Incidence reductions (per 1000 population) were greatest in children aged <12 months: 54.4 in the prevaccine era vs 30.0, 23.6, 20.0, 18.8, and 18.9 in the postvaccine years 2010-2014, respectively (a 44.9%-65.4% reduction). Lower incidence reductions (39.8%-49.4%) were observed among children aged 12-24 months from the second year post-vaccine introduction onward. Reductions were observed in both HIV-infected and HIV-uninfected children. There was a change in the seasonal pattern of diarrheal hospitalizations post-vaccine introduction, with flattening of the autumn-winter peaks seen in the prevaccine years. CONCLUSIONS An accelerated and sustained decline in all-cause diarrheal hospitalizations, temporally associated with rotavirus vaccine introduction, was observed in children <2 years of age. However, the impact of other interventions such as improved sanitation and changes in HIV management cannot be discounted.
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Affiliation(s)
- Michelle J Groome
- Medical Research Council, Respiratory and Meningeal Pathogens Research Unit Department of Science and Technology/National Research Foundation, Vaccine Preventable Diseases School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Fatima Solomon
- Medical Research Council, Respiratory and Meningeal Pathogens Research Unit Department of Science and Technology/National Research Foundation, Vaccine Preventable Diseases
| | - Susan Nzenze
- Medical Research Council, Respiratory and Meningeal Pathogens Research Unit Department of Science and Technology/National Research Foundation, Vaccine Preventable Diseases
| | - Umesh D Parashar
- Division of Viral Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Alane Izu
- Medical Research Council, Respiratory and Meningeal Pathogens Research Unit Department of Science and Technology/National Research Foundation, Vaccine Preventable Diseases
| | - Shabir A Madhi
- Medical Research Council, Respiratory and Meningeal Pathogens Research Unit Department of Science and Technology/National Research Foundation, Vaccine Preventable Diseases National Institute for Communicable Diseases, National Health Laboratory Service, Sandringham, South Africa
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Mpabalwani EM, Simwaka CJ, Mwenda JM, Mubanga CP, Monze M, Matapo B, Parashar UD, Tate JE. Impact of Rotavirus Vaccination on Diarrheal Hospitalizations in Children Aged <5 Years in Lusaka, Zambia. Clin Infect Dis 2016; 62 Suppl 2:S183-7. [PMID: 27059354 PMCID: PMC11977292 DOI: 10.1093/cid/civ1027] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/10/2025] Open
Abstract
BACKGROUND Monovalent rotavirus vaccine was introduced in the routine public health immunization program in Lusaka, Zambia, in January 2012 and was rolled out countrywide in November 2013. We examined the effect of rotavirus vaccination on hospitalization for all-cause acute gastroenteritis (AGE) and rotavirus-specific AGE at a large referral hospital in Lusaka. METHODS Data were derived from ongoing hospital-based AGE surveillance from January 2009 to December 2014. Pre-rotavirus vaccine introduction (2009-2011) and post-rotavirus vaccine introduction (2013-2014) periods were compared for annual changes in hospitalizations for AGE and rotavirus; 2012 was excluded as a transition year. Hospital administrative discharge data were used to compare trends in all-cause diarrhea discharges and in-hospital diarrhea deaths captured by HIMS pre- and post-rotavirus vaccine introduction. RESULTS Between January 2009 and December 2014, 5937 children <5 years of age presenting with AGE had their stools collected and tested for rotavirus by enzyme immunoassay. The rotavirus positivity rate declined from 40.1% (449/1121) in prevaccine years to 30.2% (250/828;P< .001) in 2013 and 24.7% (157/635;P< .001) in 2014. The greatest reduction was noted in infants, with the rotavirus positivity rate in this age group declining from 40.9% in prevaccine years to 34.0% (P= .009) in 2013 and 26.2% (P< .001) in 2014. Following rotavirus vaccine introduction, seasonal peaks of rotavirus and all-cause AGE were dwarfed. From HIMS data, compared to the prevaccine era, reductions of 18%-29% in all-cause diarrhea hospitalizations and 27%-33% in-hospital diarrhea deaths among children <1 year of age were observed in 2013 and 2014. CONCLUSIONS We observed a significant reduction in AGE-associated in-hospital morbidity and mortality following rotavirus vaccine introduction. The greatest reduction was seen in infants <1 year who accounted for 84.4% of rotavirus hospitalizations prior to vaccine introduction.
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Affiliation(s)
| | | | - Jason M Mwenda
- World Health Organization, Regional Office for Africa, Brazzaville, Republic of Congo
| | | | - Mwaka Monze
- Virology Laboratory, University Teaching Hospital, Lusaka, Zambia
| | - Belem Matapo
- World Health Organization Country Office, Lusaka, Zambia
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45
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Tate JE, Patel MM, Cortese MM, Payne DC, Lopman BA, Yen C, Parashar UD. Use of Patients With Diarrhea Who Test Negative for Rotavirus as Controls to Estimate Rotavirus Vaccine Effectiveness Through Case-Control Studies. Clin Infect Dis 2016; 62 Suppl 2:S106-14. [PMID: 27059343 PMCID: PMC11976673 DOI: 10.1093/cid/civ1014] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Case-control studies are often performed to estimate postlicensure vaccine effectiveness (VE), but the enrollment of controls can be challenging, time-consuming, and costly. We evaluated whether children enrolled in the same hospital-based diarrheal surveillance used to identify rotavirus cases but who test negative for rotavirus (test-negative controls) can be considered a suitable alternative to nondiarrheal hospital or community-based control groups (traditional controls). METHODS We compared calculated VE estimates as a function of varying values of true VE, attack rates of rotavirus and nonrotavirus diarrhea in the population, and sensitivity and specificity of the rotavirus enzyme immunoasssay. We also searched the literature to identify rotavirus VE studies that used traditional and test-negative control groups and compared VE estimates obtained using the different control groups. RESULTS Assuming a 1% attack rate for severe rotavirus diarrhea, a 3% attack rate for severe nonrotavirus diarrhea in the population, a test sensitivity of 96%, and a specificity of 100%, the calculated VE estimates using both the traditional and test-negative control groups closely approximated the true VE for all values from 30% to 100%. As true VE decreased, the traditional case-control approach slightly overestimated the true VE and the test-negative case-control approach slightly underestimated this estimate, but the absolute difference was only ±0.2 percentage points. Field VE estimates from 10 evaluations that used both traditional and test-negative control groups were similar regardless of control group used. CONCLUSIONS The use of rotavirus test-negative controls offers an efficient and cost-effective approach to estimating rotavirus VE through case-control studies.
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Affiliation(s)
| | - Manish M Patel
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | | | - Daniel C Payne
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | | | - Catherine Yen
- Centers for Disease Control and Prevention, Atlanta, Georgia
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46
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Ngabo F, Tate JE, Gatera M, Rugambwa C, Donnen P, Lepage P, Mwenda JM, Binagwaho A, Parashar UD. Effect of pentavalent rotavirus vaccine introduction on hospital admissions for diarrhoea and rotavirus in children in Rwanda: a time-series analysis. Lancet Glob Health 2016; 4:e129-36. [PMID: 26823214 PMCID: PMC11976669 DOI: 10.1016/s2214-109x(15)00270-3] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2015] [Revised: 10/22/2015] [Accepted: 11/02/2015] [Indexed: 11/26/2022]
Abstract
BACKGROUND In May, 2012, Rwanda became the first low-income African country to introduce pentavalent rotavirus vaccine into its routine national immunisation programme. Although the potential health benefits of rotavirus vaccination are huge in low-income African countries that account for more than half the global deaths from rotavirus, concerns remain about the performance of oral rotavirus vaccines in these challenging settings. METHODS We conducted a time-series analysis to examine trends in admissions to hospital for non-bloody diarrhoea in children younger than 5 years in Rwanda between Jan 1, 2009, and Dec 31, 2014, using monthly discharge data from the Health Management Information System. Additionally, we reviewed the registries in the paediatric wards at six hospitals from 2009 to 2014 and abstracted the number of total admissions and admissions for diarrhoea in children younger than 5 years by admission month and age group. We studied trends in admissions specific to rotavirus at one hospital that had undertaken active rotavirus surveillance from 2011 to 2014. We assessed changes in rotavirus epidemiology by use of data from eight active surveillance hospitals. FINDINGS Compared with the 2009-11 prevaccine baseline, hospital admissions for non-bloody diarrhoea captured by the Health Management Information System fell by 17-29% from a pre-vaccine median of 4051 to 2881 in 2013 and 3371 in 2014, admissions for acute gastroenteritis captured in paediatric ward registries decreased by 48-49%, and admissions specific to rotavirus captured by active surveillance fell by 61-70%. The greatest effect was recorded in children age-eligible to be vaccinated, but we noted a decrease in the proportion of children with diarrhoea testing positive for rotavirus in almost every age group. INTERPRETATION The number of admissions to hospital for diarrhoea and rotavirus in Rwanda fell substantially after rotavirus vaccine implementation, including among older children age-ineligible for vaccination, suggesting indirect protection through reduced transmission of rotavirus. These data highlight the benefits of routine vaccination against rotavirus in low-income settings. FUNDING Gavi, the Vaccine Alliance and the Government of Rwanda.
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Affiliation(s)
- Fidele Ngabo
- Université Libre de Bruxelles, Ecole de Santé Publique, Centre de Recherche Politiques et Systèmes de Santé-Santé Internationale, Brussels, Belgium.
| | | | | | - Celse Rugambwa
- World Health Organization, Rwanda Office, Kigali, Rwanda
| | - Philippe Donnen
- Université Libre de Bruxelles, Ecole de Santé Publique, Centre de Recherche Politiques et Systèmes de Santé-Santé Internationale, Brussels, Belgium
| | - Philippe Lepage
- Hôpital Universitaire des Enfants Reine Fabiola (HUDERF), Brussels, Belgium
| | - Jason M Mwenda
- World Health Organization, African Regional Office, Brazzaville, Congo
| | - Agnes Binagwaho
- Ministry of Health, Kigali, Rwanda; Harvard Medical School, Boston, MA, USA; Geisel School of Medicine, Dartmouth College, Hanover, NH, USA
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Abstract
PURPOSE OF REVIEW Childhood diarrhea is the most common cause of morbidity and mortality, especially in the low and middle-income countries. The burden of child mortality because of diarrhea has declined, but still a lot is desired not only to reduce diarrhea-specific mortality but reduce the overall incidence, and hence the morbidity associated with childhood diarrhea. RECENT FINDINGS A recent Lancet series on diarrhea suggests that amplification of the current interventions can eliminate virtually all preventable diarrhea deaths. A refocused attention and strategy and collective effort from the multilateral entities to promote water sanitation and hygiene, rotavirus vaccination, nutrition, and improved case management can bridge gaps and tackle the existing undue burden of deaths because of diarrhea. SUMMARY Investment toward preventing and controlling childhood diarrhea should be a priority, especially when the existing solution is plausible for implementation at scale and in underprivileged settings.
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48
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Abstract
BACKGROUND Postlicensure surveillance studies suggest a small temporal increase in the risk for intussusception with both currently available rotavirus vaccines (RV1; Rotarix, GSK and RV5; RotaTeq, Merck & Co., Inc.). This meta-analysis was undertaken to provide a single overall estimate of the relative risk of intussusception during the 7-day period after administration of RV1 and RV5. METHODS Meta-analysis based on estimates of relative risk and corresponding 95% confidence intervals from 5 postlicensure studies providing an estimate of risk of intussusception during the 7-day period after administration of dose 1 and/or dose 2 of RV1 and/or RV5, based on active and/or passive surveillance, for confirmed intussusception cases (Brighton or other method of case confirmation). For each vaccine, the relative risk of intussusception was estimated postdose 1 and postdose 2. Results were pooled using the inverse variance method using both fixed-effect and random-effect models. RESULTS The overall estimate of relative risk of intussusception during the 7 days postdose 1 was 5.4 (95% confidence interval: 3.9-7.4, 3 studies) for RV1 and 5.5 (3.3-9.3, 3 studies) for RV5. The overall estimate of relative risk of intussusception during the 7 days postdose 2 was 1.8 (1.3-2.5, 4 studies) for RV1 and 1.7 (1.1-2.6, 3 studies) for RV5. CONCLUSIONS This meta-analysis showed a similar increased risk of intussusception, during the first 7 days after administration of dose 1 and, to a lesser extent, dose 2, for both currently available rotavirus vaccines. This suggests that intussusception may be a class effect of currently available oral rotavirus vaccines.
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O’Ryan M, Giaquinto C, Benninghoff B. Human rotavirus vaccine (Rotarix): focus on effectiveness and impact 6 years after first introduction in Africa. Expert Rev Vaccines 2015; 14:1099-112. [DOI: 10.1586/14760584.2015.1059282] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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50
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Kiulia NM, Hofstra N, Vermeulen LC, Obara MA, Medema G, Rose JB. Global occurrence and emission of rotaviruses to surface waters. Pathogens 2015; 4:229-55. [PMID: 25984911 PMCID: PMC4493472 DOI: 10.3390/pathogens4020229] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2015] [Revised: 05/06/2015] [Accepted: 05/07/2015] [Indexed: 01/03/2023] Open
Abstract
Group A rotaviruses (RV) are the major cause of acute gastroenteritis in infants and young children globally. Waterborne transmission of RV and the presence of RV in water sources are of major public health importance. In this paper, we present the Global Waterborne Pathogen model for RV (GloWPa-Rota model) to estimate the global distribution of RV emissions to surface water. To our knowledge, this is the first model to do so. We review the literature to estimate three RV specific variables for the model: incidence, excretion rate and removal during wastewater treatment. We estimate total global RV emissions to be 2 × 1018 viral particles/grid/year, of which 87% is produced by the urban population. Hotspot regions with high RV emissions are urban areas in densely populated parts of the world, such as Bangladesh and Nigeria, while low emissions are found in rural areas in North Russia and the Australian desert. Even for industrialized regions with high population density and without tertiary treatment, such as the UK, substantial emissions are estimated. Modeling exercises like the one presented in this paper provide unique opportunities to further study these emissions to surface water, their sources and scenarios for improved management.
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Affiliation(s)
- Nicholas M Kiulia
- Department of Fisheries and Wildlife, Michigan State University East Lansing, MI 48824, USA.
- Enteric Viruses Research Group, Institute of Primate Research, P.O Box 24481, 00502 Karen, Nairobi, Kenya.
| | - Nynke Hofstra
- Environmental Systems Analysis Group, Wageningen University, P.O. Box 47, 6700 AA, Wageningen, The Netherlands.
| | - Lucie C Vermeulen
- Environmental Systems Analysis Group, Wageningen University, P.O. Box 47, 6700 AA, Wageningen, The Netherlands.
| | - Maureen A Obara
- Department of Fisheries and Wildlife, Michigan State University East Lansing, MI 48824, USA.
| | - Gertjan Medema
- Faculty of Civil Engineering and Geosciences, Delft University of Technology, P.O. Box 5048, 2600 GA, Delft, the Netherlands.
- KWR Watercycle Research Institute, Groningenhaven 7, 3433 PE, Nieuwegein, The Netherlands.
| | - Joan B Rose
- Department of Fisheries and Wildlife, Michigan State University East Lansing, MI 48824, USA.
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