Sustained low rotavirus activity and hospitalisation rates in the post-vaccination era in Belgium, 2007 to 2014

Co-administration with Men-B vaccine increases Rotavirus vaccination coverage: A 5-year regionwide retrospective cohort study (STORM study)

INTRODUCTION

In Italy Rotavirus vaccination (RVV) is provided free of charge from 2018, however, the coverage is scattered and suboptimal. The narrow time frame to complete the schedule is a barrier to uptake, and co-administration with other vaccines may potentially increase the coverage. Although the co-administration of RV vaccine and Meningococcal Group B vaccine (MenB) is not included in the product labels, we aimed at studying its impact on RVV coverage.

METHODS

This Surveillance study on Timing and cOverage of Rotavirus and MenB vaccine co-administration (STORM study) used the Regional Vaccination Registry to collect data about children born in Campania Region between January 2016 and December 2020, and receiving vaccines scheduled in the first year of life.

RESULTS

Among the 224,110 children enrolled, 60,614 (27.0%) completed the RVV schedule, with a vaccination rate that increased over time from 1.15% in 2016 to 56.92% in 2020. The first and last dose of RVV schedule were administered beyond the recommended time in 6% of the study population, respectively. Co-administration of RV vaccine with MenB vaccine increased from 0.7 % in 2016 to 46.85 % in 2020. Children receiving RV/MenB vaccines concomitantly had a significantly higher chance of completing the RV schedule compared to those receiving RVV alone during a specific appointment (94.78 % vs 72.26 %, Prevalence Ratio -PR- 1.275, 95 %CI 1.245-1.295p < 0.00001). The positive driving effect of RV/MenB co-administration was more evident for children receiving pentavalent (PR 1.288) than monovalent RVV (PR 1.115) which was confirmed when adjusted for confounding variables (i.e., year of vaccination, local district, gender).

CONCLUSIONS

Although still far from the target, RVV coverage has increased in recent years in Campania Region. Co-administration with MenB vaccine may aid in increasing RVV coverage, especially for pentavalent RVV. Further safety data are needed to support co-administration as a key tool to increase coverage.

Prevalence and genomic analysis of t203-like G9 (G9-VI) rotaviruses circulating in children with gastroenteritis in Beijing, China

Our previous surveillance revealed that t203-like G9 (tentatively designated subtype G9-VI) rotaviruses re-emerged in 2010 in Beijing and rapidly prevailed over the G9-III subtype (the most common G9 subtype globally) and previously predominant G genotypes over the following two years. G9-VI belongs to the VP7 evolutionary lineage VI, which includes unusual and sporadic human rotaviruses from China (t203) and Japan. To obtain insight into the epidemiology, evolution, and transmission advantages of G9-VI rotavirus, we performed follow-up surveillance (2014-2017) and whole-genome analysis of 12 representative G9 strains. The results showed that the G9 genotype was predominant (77.4%), with a marked increase in prevalence (previously 43.5%). Within the G9 genotype, subtype G9-VI accounted for the majority (98.3%) of cases. The most prevalent P-genotype was P[8] (93.7%), within which subtype P[8]b was rare (0.7%). Phylogenetically, the G9-VI subtype strains in this study clustered closely with contemporary emerging human rotaviruses from many other countries in VP7 lineage VI, indicating that this subtype is capable of spreading globally. These currently emerging G9-VI rotaviruses formed a distinct monophyletic subcluster when compared to early G9-VI rotaviruses. Furthermore, four specific amino acid substitutions and synonymous codon substitutions were observed in the VP7 genes between the current G9-VI and globally common G9-III rotaviruses. The remaining nine genes of all of the analyzed representative G9 strains, whether G9-VI or G9-III, combined with the P[8]a, P[8]b, or P[6] genotype and exhibited the same Wa-like backbone constellation.

Public health impact and return on investment of Belgium's pediatric immunization program

Objective

We evaluated the public health impact and return on investment of Belgium's pediatric immunization program (PIP) from both healthcare-sector and societal perspectives.

Methods

We developed a decision analytic model for 6 vaccines routinely administered in Belgium for children aged 0-10 years: DTaP-IPV-HepB-Hib, DTaP-IPV, MMR, PCV, rotavirus, and meningococcal type C. We used separate decision trees to model each of the 11 vaccine-preventable pathogens: diphtheria, tetanus, pertussis, poliomyelitis, Haemophilus influenzae type b, measles, mumps, rubella, Streptococcus pneumoniae, rotavirus, and meningococcal type C; hepatitis B was excluded because of surveillance limitations. The 2018 birth cohort was followed over its lifetime. The model projected and compared health outcomes and costs with and without immunization (based on vaccine-era and pre-vaccine era disease incidence estimates, respectively), assuming that observed reductions in disease incidence were fully attributable to vaccination. For the societal perspective, the model included productivity loss costs associated with immunization and disease in addition to direct medical costs. The model estimated discounted cases averted, disease-related deaths averted, life-years gained, quality-adjusted life-years gained, costs (2020 euros), and an overall benefit-cost ratio. Scenario analyses considered alternate assumptions for key model inputs.

Results

Across all 11 pathogens, we estimated that the PIP prevented 226,000 cases of infections and 200 deaths, as well as the loss of 7,000 life-years and 8,000 quality-adjusted life-years over the lifetime of a birth cohort of 118,000 children. The PIP was associated with discounted vaccination costs of €91 million from the healthcare-sector perspective and €122 million from the societal perspective. However, vaccination costs were more than fully offset by disease-related costs averted, with the latter amounting to a discounted €126 million and €390 million from the healthcare-sector and societal perspectives, respectively. As a result, pediatric immunization was associated with overall discounted savings of €35 million and €268 million from the healthcare-sector and societal perspectives, respectively; every €1 invested in childhood immunization resulted in approximately €1.4 in disease-related cost savings to the health system and €3.2 in cost savings from a societal perspective for Belgium's PIP. Estimates of the value of the PIP were most sensitive to changes in input assumptions for disease incidence, productivity losses due to disease-related mortality, and direct medical disease costs.

Conclusion

Belgium's PIP, which previously had not been systematically assessed, provides large-scale prevention of disease-related morbidity and premature mortality, and is associated with net savings to health system and society. Continued investment in the PIP is warranted to sustain its positive public health and financial impact.

The Economic Value of Rotavirus Vaccination When Optimally Implemented in a High-Income Country

Rotavirus vaccination was introduced in high-income countries starting in 2006, with no recommendation for optimal implementation. Economic evaluations were presented before launch projecting potential impacts. Few economic reassessments have been reported following reimbursement. This study compares the short- to long-term economic value of rotavirus vaccination between pre-launch predictions and real-world evidence collected over 15 years, proposing recommendations for optimal vaccine launch. A cost-impact analysis compared rotavirus hospitalisation data after the introduction of vaccination between pre-launch modelled projections and observed data collected in the RotaBIS study in Belgium. A best model fit of the observed data was used to simulate launch scenarios to identify the optimal strategy. Data from other countries in Europe were used to confirm the potential optimal launch assessment. The Belgian analysis in the short term (first 8 years) indicated a more favourable impact for the observed data than predicted pre-launch model results. The long-term assessment (15 years) showed bigger economic disparities in favour of the model-predicted scenario. A simulated optimal vaccine launch, initiating the vaccination at least 6 months prior the next seasonal disease peak with an immediate very high vaccine coverage, indicated important additional potential gains, which would make vaccination very cost impactful. Finland and the UK are on such a route leading to long-term vaccination success, whereas Spain and Belgium have difficulties in achieving optimum vaccine benefits. An optimal launch of rotavirus vaccination may generate substantial economic gains over time. For high-income countries that are considering implementing rotavirus vaccination, achieving an optimal launch is a critical factor for long-term economic success.

Circulation of Vaccine-derived Rotavirus G1P[8] in a Vulnerable Child Cohort in Rio de Janeiro

BACKGROUND

The expansion of rotavirus (RV) immunization in several countries reduced the burden of acute diarrheal disease (ADD) and diarrhea-associated mortality. Although community transmission of live attenuated monovalent rotavirus vaccine (G1P[8] RV1) virus has been demonstrated in children and household contacts, fecal shedding of these strains in neonates and infants under six weeks of age has never been demonstrated. The objective of the study was to assess ADD and rotavirus vaccine strain shedding before and after immunization through 24 months of age.

METHODS

This was a prospective cohort study in a low-resource community in which stool samples were collected from neonates from 15 to 45 days of age every 2 weeks, after both doses of G1P[8] RV1, and in subsequent ADD episodes until 2 years of age. RV was detected and genotyped in stool samples by RT-PCR.

RESULTS

We enrolled 242 participants who were followed for an average of 23 months. The specific prevalence of G1P[8] RV1 virus was 3.3% in neonates and infants less than six weeks of age, 50% after the first dose, and 25.6% after the second dose. Among the 70 participants with ADD, G1P[8] RV1 virus was identified in only one participant (1.4% prevalence).

CONCLUSIONS

In vaccinated children, there were no breakthrough infections with G1P[8] RV1 and ADD was rare supporting high vaccine effectiveness. We observed G1P[8] RV1 virus shedding among neonates and infants before the first vaccine dose, providing evidence of transmission of the vaccine strain from immunized children to those who are not yet vaccinated.

Public health impact and return on investment of the pediatric immunization program in Poland

BACKGROUND

This study aims to evaluate the epidemiological impact and return on investment of the pediatric immunization program (PIP) in Poland from the healthcare-sector and societal perspectives.

RESEARCH DESIGN AND METHODS

A health-economic model was developed focusing on the nine vaccines, targeting 11 pathogens, recommended by the public health authorities for children aged 0-6 years in Poland. The 2019 birth cohort (388,178) was followed over their lifetime, with the model estimating discounted health outcomes, life-years gained, quality-adjusted life-years, and direct and indirect costs with and without the PIP based on current and pre-vaccine - era disease incidence estimates, respectively.

RESULTS

Across 11 targeted pathogens, the Polish PIP prevented more than 452,300 cases of disease, 1,600 deaths, 37,900 life-years lost, and 38,800 quality-adjusted life-years lost. The PIP was associated with vaccination costs of €54 million. Pediatric immunization averted €65 million from a healthcare-sector perspective (benefit-cost ratio [BCR], 2.2) and averted €358 million from a societal perspective (BCR, 7.6). The BCRs from both perspectives remained >1.0 in scenario analyses.

CONCLUSIONS

The Polish PIP, which has not previously been systematically assessed, brings large-scale prevention of disease-related morbidity, premature mortality, and associated costs. This analysis highlights the value of continued investment in pediatric immunization in Poland.

The Value of Rotavirus Vaccination in Europe: A Call for Action

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic has pushed many healthcare systems into crisis. High vaccine coverage amongst children reduces emergency room presentations, hospital admissions and deaths due to vaccine-preventable diseases, freeing up healthcare resources including polymerase chain reaction testing for patients with SARS-CoV-2. In Europe, rotavirus gastroenteritis leads to 75,000-150,000 hospitalisations and up to 600,000 medical encounters annually. Nevertheless, in 2022, only 18 countries in Europe (out of 38) have a publicly funded routine universal mass immunisation programme against rotavirus gastroenteritis. Evidence available in the last few years re-emphasises that rotavirus vaccines currently available in Europe are highly effective, preventing up to 96% of rotavirus-related hospitalisations in children less than 1 year of age (potentially 72,000-144,000 hospitalisations Europe-wide). Long-term surveillance indicates that rotavirus vaccination does not result in an overall increase in intussusception. On the contrary, increasing evidence suggests an overall reduction in intussusception in the first 12 months of life when early, high rotavirus vaccine coverage is achieved. Prevention of rotavirus gastroenteritis has marked positive impacts on parental wages and government tax revenue, with benefits extending across the whole economy. In the SARS-CoV-2 pandemic setting there is a new imperative to achieve high levels of paediatric vaccination against vaccine-preventable diseases, including rotavirus gastroenteritis. The introduction of rotavirus universal mass vaccination can be expected to reduce the number of preventable illnesses, hospitalisations and deaths caused by rotavirus gastroenteritis. Reducing vaccine-preventable diseases is particularly urgent at this time when healthcare systems are preoccupied and overwhelmed with SARS-CoV-2. Graphical abstract available for this article.

Rotavirus epidemiology and genotype distribution in hospitalised children, Greece, 2008 to 2020: A prospective multicentre study

BackgroundTwo rotavirus (RV) vaccines were licensed in Greece in late 2006 and included in the national immunisation programme in 2012.AimTo study the epidemiology and genotype distribution of RV in children during the post-vaccination period and assess the impact of increased vaccination coverage.MethodsIn a prospective multicentre hospital-based study, hospitalised children (≤ 16 years) with an RV-positive faecal sample were recruited. Epidemiological and genotyping analyses were performed; periods of low (2008-12) and moderate (2012-20) RV vaccination coverage were compared. Statistical analysis was performed with a chi-squared or Mann-Whitney U test and logistic regression.ResultsA total of 3,874 children (55.6% male; n = 2,153) with median age of 1.4 years (IQR: 0.5-3.3) were studied during 2008-20. Most RV-infected children were aged ≤ 3 years (72.2%) and hospitalised during December-May (69.1%). Common RV genotypes (G1P[8], G2P[4], G3P[8], G4P[8], G9P[8], G12P[8]) were detected in 92.2% of samples; G-P combinations with prevalence above 1% were G4P[8] (44.1%), G1P[8] (25.4%), G2P[4] (14.9%), G9P[8] (3.5%), G12P[8] (2.2%), G3P[8] (2.1%), other (4.3%) and mixed (3.5%). Of all samples, 97.6% were homotypic or partially heterotypic to vaccines' genotypes. With moderate vaccination coverage, the seasonal peak was detected earlier, children were older and partially or fully heterotypic genotypes were increased (p < 0.001).ConclusionsIn the era of moderate RV vaccination coverage in Greece, epidemiology of RV in hospitalised children seemed to change. However, most circulating genotypes remain homotypic or partially heterotypic to RV vaccines. Continuous epidemiological surveillance and genotyping are important to monitor possible changes arising from RV vaccines' implementation.

Rotavirus epidemiology and genotype distribution in hospitalised children, Greece, 2008 to 2020: A prospective multicentre study

BackgroundTwo rotavirus (RV) vaccines were licensed in Greece in late 2006 and included in the national immunisation programme in 2012.AimTo study the epidemiology and genotype distribution of RV in children during the post-vaccination period and assess the impact of increased vaccination coverage.MethodsIn a prospective multicentre hospital-based study, hospitalised children (≤ 16 years) with an RV-positive faecal sample were recruited. Epidemiological and genotyping analyses were performed; periods of low (2008-12) and moderate (2012-20) RV vaccination coverage were compared. Statistical analysis was performed with a chi-squared or Mann-Whitney U test and logistic regression.ResultsA total of 3,874 children (55.6% male; n = 2,153) with median age of 1.4 years (IQR: 0.5-3.3) were studied during 2008-20. Most RV-infected children were aged ≤ 3 years (72.2%) and hospitalised during December-May (69.1%). Common RV genotypes (G1P[8], G2P[4], G3P[8], G4P[8], G9P[8], G12P[8]) were detected in 92.2% of samples; G-P combinations with prevalence above 1% were G4P[8] (44.1%), G1P[8] (25.4%), G2P[4] (14.9%), G9P[8] (3.5%), G12P[8] (2.2%), G3P[8] (2.1%), other (4.3%) and mixed (3.5%). Of all samples, 97.6% were homotypic or partially heterotypic to vaccines' genotypes. With moderate vaccination coverage, the seasonal peak was detected earlier, children were older and partially or fully heterotypic genotypes were increased (p < 0.001).ConclusionsIn the era of moderate RV vaccination coverage in Greece, epidemiology of RV in hospitalised children seemed to change. However, most circulating genotypes remain homotypic or partially heterotypic to RV vaccines. Continuous epidemiological surveillance and genotyping are important to monitor possible changes arising from RV vaccines' implementation.

Characterization of Rotavirus Infection in Hospitalized Children under 5 with Acute Gastroenteritis 5 Years after Introducing the Rotavirus Vaccines in South Korea

We herein characterized rotavirus infection in hospitalized children under 5 years of age with gastroenteritis after introducing rotavirus vaccines in South Korea from 20 February 2012, to 31 March 2013. Enzyme-linked fluorescent immunoassay was performed to detect rotavirus antigens. G and P genotyping was performed using nested multiplex PCR. For the failed PCR samples, sequencing was conducted. We performed a test-negative case-control study to estimate vaccine effectiveness. Vaccine effectiveness was measured using a multivariate logistic regression model. Rotavirus was detected in 16 (13.2%) of the 121 patients, with a seasonal peak in April 2012. The dominant genotypes detected were G3P[8] (33.3%) and G4P[6] (26.7%), and vaccine effectiveness against rotavirus hospitalization was 84.9% [95% CI: 23.2−97.0] in the complete vaccinated group. A higher prevalence of rotavirus infection was observed among children with siblings than those without siblings (p < 0.001). Also, the presence of siblings was significantly associated with a history of nonvaccination (p < 0.001). In conclusion, the prevalence of rotavirus followed a decreasing trend, and there was no evidence of emergences of nonvaccine-type strains. Vaccine effectiveness against rotavirus hospitalization was 84.9%. Although children with siblings were more susceptible to rotavirus infection, they were less likely to receive vaccination against rotavirus.

Real-world impact of rotavirus vaccination in European healthcare settings: a systematic literature review

INTRODUCTION

Rotavirus is one of the most common pathogens causing diarrhea in children <5 years and has a major impact on childhood morbidity and mortality. Since the implementation of rotavirus vaccines into childhood immunization programs across Europe, there has been a reduction in rotavirus burden, including hospitalizations, outpatient cases, costs, and deaths.

AREAS COVERED

A systematic literature review identified publications describing the clinical and economic impact of rotavirus vaccinations across Europe, from their introduction in 2006 to the end of 2020. A total of 3,137 articles were identified, of which 46 were included in the review. Included articles reported the impact of rotavirus vaccination on disease in any age group.

EXPERT OPINION

Rotavirus vaccination has resulted in substantial reductions in hospitalizations and rotavirus-associated costs across Europe, particularly in children <5 years. There is some evidence of herd protection afforded to older age groups where vaccine uptake is high among infants, highlighting the potential for vaccination to confer a greater societal benefit as programs become more established. Increasing vaccination coverage and continuing investment in widespread rotavirus vaccination programs across countries will likely increase the substantial public health benefits associated with vaccination and further reduce the clinical and economic burden of disease.

Impact analysis of rotavirus vaccination in various geographic regions in Western Europe

BACKGROUND

Universal mass vaccination (UMV) against rotavirus has been implemented in many but not all European countries. This study investigated the impact of UMV on rotavirus incidence trends by comparing European countries with UMV: Belgium, England/Wales and Germany versus countries without UMV: Denmark and the Netherlands.

METHODS

For this observational retrospective cohort study, time series data (2001-2016) on rotavirus detections, meteorological factors and population demographics were collected. For each country, several meteorological and population factors were investigated as possible predictors of rotavirus incidence. The final set of predictors were incorporated in negative binomial models accounting for seasonality and serial autocorrelation, and time-varying incidence rate ratios (IRR) were calculated for each age group and country separately. The overall vaccination impact two years after vaccine implementation was estimated by pooling the results using a random effects meta-analyses. Independent t-tests were used to compare annual epidemics in the pre-vaccination and post-vaccination era to explore any changes in the timing of rotavirus epidemics.

RESULTS

The population size and several meteorological factors were predictors for the rotavirus epidemiology. Overall, we estimated a 42% (95%-CI 23;56%) reduction in rotavirus incidence attributable to UMV. Strongest reductions were observed for age-groups 0-, 1- and 2-years (IRR 0.47, 0.48 and 0.63, respectively). No herd effect induced by UMV in neighbouring countries was observed. In all UMV countries, the start and/or stop and corresponding peak of the rotavirus season was delayed by 4-7 weeks.

CONCLUSIONS

The introduction of rotavirus UMV resulted in an overall reduction of 42% in rotavirus incidence in Western European countries two years after vaccine introduction and caused a change in seasonal pattern. No herd effect induced by UMV neighbouring countries was observed for Denmark and the Netherlands.

All-cause gastroenteritis hospitalisations of children decreased after the introduction of rotavirus vaccine in Stockholm

BACKGROUND

In Stockholm, Sweden, rotavirus vaccination was offered to children born after 1 March 2014. Our aim was to describe rates of hospitalisation due to community-acquired gastroenteritis before and after the introduction of the vaccine, and aetiology, underlying medical conditions and complications in admitted children.

METHODS

We retrospectively included patients from our catchment area hospitalised with a diagnosis of gastroenteritis during ten infection seasons 2008/2009-2017/2018, whereof six seasons prevaccination and four seasons postvaccination. We studied virus detection data and the patients' medical records.

RESULTS

We included 3718 episodes in 3513 children. In 2967 (80%), stools were tested with virus isolation, ELISA, PCR, or bacterial culture; 479 (16%) tested negative. The incidence rates, with 95% confidence intervals, for children <5 years hospitalised for rotavirus gastroenteritis were 2.9 (2.8-3.1) per 1000 person-years prevaccination and 0.65 (0.56-0.74) postvaccination, for a rate ratio (RR) of 0.22 (0.19-0.26, p < .001). The rates for all-cause gastroenteritis were 5.6 (5.4-5.9) prevaccination and 2.5 (2.3-2.7) postvaccination, RR 0.45 (0.42-0.50, p < .001). In 5-17-year-old children norovirus dominated with little change over time. Of patients <5 years, those with underlying conditions constituted a larger proportion postvaccination than prevaccination (30.7% vs. 24.2%, p < .001). A complication other than dehydration, most commonly seizures, arose in 8.8% of the patients <5 years prevaccination and 11.4% postvaccination (p < .05).

CONCLUSIONS

Rotavirus vaccination reduced the number of children <5 years requiring hospital care for gastroenteritis. We saw no replacement of rotavirus by other viruses.

Burden of rotavirus disease in young children in Iceland - Time to vaccinate?

BACKGROUND

Acute gastroenteritis poses a significant burden on young children, families, health care facilities and societies. Rotavirus is the most common pathogen, but rotavirus infections are vaccine preventable. Information on the epidemiology of gastroenteritis in Icelandic children has until now not been available and rotavirus vaccination is currently not offered to Icelandic infants. The objective of this study was to assess the burden of rotavirus acute gastroenteritis in young children in Iceland and determine the potential benefit of adding rotavirus vaccine to the Icelandic childhood immunization schedule.

METHODS

For a two-year period, children < 6 years old attending a children's emergency department for acute gastroenteritis were recruited at the Children's Hospital in Reykjavík, Iceland. Demographic information and Vesikari scores were registered. Stool samples were analyzed for pathogens. Duration of symptoms, treatment given, and secondary household infections were among the collected information. Annual cost of the infections in young children was estimated based on health care expenditures and lost days of parental work.

RESULTS

325 children were included in the study, 75% of which were ≤ 24 months old. A pathogen was identified in 80% of cases, of which rotavirus was identified in 54%. Rotavirus caused a more severe disease than other pathogens, more often leading to fluid treatment in the emergency department and admissions. Median duration of rotavirus-illness was six days and caused a median of four days lost from work by parents. The estimated annual cost of rotavirus acute gastroenteritis was €2.9 million.

CONCLUSIONS

Rotavirus causes significant disease burden in young children. Although rarely life-threatening in high income countries, the costs for society are substantial. The inclusion of rotavirus vaccine in the national immunization schedule will reduce the disease burden and would be cost-saving in Iceland.

Rotavirus gastroenteritis in children hospitalized in northeastern Poland in 2006-2020: Severity, seasonal trends, and impact of immunization

OBJECTIVES

The introduction of the rotavirus vaccine in 2006 significantly reduced childhood incidence of acute gastroenteritis (AGE) worldwide. The rotavirus vaccine was included in Poland's national immunization program in 2021. Our study aimed to summarize the epidemiology of AGE in northeastern Poland prior to 2021 and to evaluate the effectiveness of voluntary, out-of-pocket rotavirus childhood vaccination on the incidence of rotavirus AGE.

METHODS

A review of patients aged 0-17 years with gastroenteritis hospitalized between 2006 and 2020 in northeastern Poland in the context of rotavirus vaccine coverage in the region.

RESULTS

Rotavirus was the most common agent of gastroenteritis in hospitalized patients. The seasonality of rotavirus gastroenteritis peaked between February and May in each year of study, except for 2020, when the COVID-19 pandemic skewed any viable comparison of seasonality. Rotavirus vaccine coverage in northeastern Poland did not exceed 25% during the study period and had no impact on hospitalization numbers.

CONCLUSIONS

Rotavirus was the primary causative agent of AGE in children hospitalized in northeastern Poland during the study period. Voluntary vaccinations did not affect the number of hospitalizations due to rotavirus AGE. Our data suggest that universal immunization is key to achieving a significant reduction of rotavirus-associated diarrhea.

Sustained declines in age group-specific rotavirus infection and acute gastroenteritis in vaccinated and unvaccinated individuals during the five years since Rotavirus vaccine introduction in England

BACKGROUND

The introduction of an oral live-attenuated monovalent rotavirus vaccine (Rotarix ®) into the UK infant immunisation programme in July 2013 was associated with large reductions in laboratory-confirmed rotavirus infections and hospitalisations due to acute gastroenteritis (AGE) within 12 months. Here we report the five-year impact of the programme in England.

METHODS

Individuals with laboratory-confirmed rotavirus infections during 2000-2018 and all-cause hospitalisations for AGE during 2007-2018 were identified using national electronic records. Age-specific incidence rate ratios (IRR) and estimated numbers of cases averted in each of the five post-vaccination years were calculated.

RESULTS

There were 206,389 laboratory-confirmed rotavirus infections and 3,657,651 hospitalisations for all-cause AGE. Reductions of 69-83% in laboratory-confirmed rotavirus infections in all age groups and 77-88% in infants aged <1 year in each of the five post-vaccine years are reported, with 11,386-11,633 cases averted annually. All-cause AGE hospitalisations were reduced by 12-35% across all age-groups and by 25-48% in <1 year-olds in the five post-vaccine years, with 24,474-49,278 hospitalisations averted annually. There was strong evidence of indirect (herd) protection, with at least 50% and up to 80% of the non-specific end point of all-cause gastroenteritis (AGE) hospitalisations averted being in unvaccinated age-groups, primarily older adults. Seasonal changes include a possible shift from annual to biennial peaks with lower peak incidence and longer seasons.

CONCLUSIONS

There were large and sustained declines in both laboratory-confirmed rotavirus infections and AGE hospitalisations across all age groups in each of the five years since the introduction of the UK rotavirus programme.

Impact of the Rotavirus Vaccination Program in Norway After Four Years With High Coverage

BACKGROUND

Use of rotavirus vaccines worldwide since 2006 has led to a significant impact on the burden of rotavirus disease. However, only a third of European countries have introduced rotavirus vaccination in their immunization programs. In October 2014, rotavirus vaccination was introduced for Norwegian infants under strict age restrictions. Exclusive use of the monovalent rotavirus vaccine (RV1) and high vaccination coverage from the beginning enabled evaluation of the impact of this vaccine during the first 4 years after introduction.

METHODS

Prospective laboratory-based surveillance among children <5 years of age hospitalized for acute gastroenteritis at 5 Norwegian hospitals was used to assess the vaccine effectiveness of 2 vaccine doses against rotavirus hospitalization in a case-control study. We used community controls selected from the national population-based immunization registry, and test-negative controls recruited through hospital surveillance. We also assessed the vaccine impact by using time-series analysis of retrospectively collected registry data on acute gastroenteritis in primary and hospital care during 2009-2018.

RESULTS

Vaccine effectiveness against rotavirus-confirmed hospitalization was 76% (95% confidence interval [CI]: 34%-91%) using test-negative controls, and 75% (95% CI: 44%-88%) using community controls. In the postvaccine period, acute gastroenteritis hospitalizations in children <5 years were reduced by 45% compared with the prevaccine years (adjusted incidence rate ratios 0.55; 95% CI: 0.49-0.61). Reduction in hospitalizations was also seen in cohorts not eligible for vaccination. Rates in primary care decreased to a lesser degree.

CONCLUSIONS

Four years after introduction of rotavirus vaccination in the national childhood immunization program, we recorded a substantial reduction in the number of children hospitalized for acute gastroenteritis in Norway, attributable to a high vaccine effectiveness.

Rotavirus vaccine administration patterns in Italy: potential impact on vaccine coverage, compliance and adherence

Acceptance of rotavirus (RV) vaccination may be impacted by several factors including the feasibility of the full schedule administration within the fixed immunization timelines. The human RV vaccine Rotarix (GSK) and the human bovine reassortant vaccine RotaTeq (Merck & Co.) were developed with different posologies (2 doses vs 3 doses respectively), which have both scientific and technical implications. A non-systematic literature review revealed that, in the Italian context, topics such as time to achieve RV protection in children, number of preventable cases and administration time window, compatibility/ease of inclusion in the national vaccination calendar, potential overlaps with the peak of natural history of intussusception and adherence to posology could be impacted by the RV vaccine posology. Results suggest that a shorter schedule would allow for greater flexibility of use as well as a greater documented ease of inclusion in the vaccination calendar, thereby reducing potential direct healthcare costs.

Impact of Routine Rotavirus Vaccination in Germany: Evaluation Five Years After Its Introduction

BACKGROUND

Routine rotavirus (RV)-vaccination is recommended in Germany since August 2013. Five years later, we evaluated the recommendation by examining vaccine uptake and the impact on RV-gastroenteritis (RVGE) burden in all age groups and on intussusceptions in infants.

METHODS

We estimated RV-vaccine uptake in the 2014-2018 birth cohorts using statutory health insurance prescription data. For impact assessment, we analyzed RVGE-surveillance data of the German infectious diseases notification system. We compared age-specific RVGE-incidences of different severity between pre-vaccination (2005/06-2007/08) and routine vaccination period (2013/14-2017/18) calculating incidence rate ratios (IRR) using Poisson regression. To determine the effect on intussusception, we used hospital discharge data (2006-2017) and compared incidences between pre-vaccination and routine vaccination period using Poisson regression.

RESULTS

Vaccination coverage increased from 59% (2014) to 80% (2018). Incidences of RVGE-outpatient cases, RVGE-hospitalization and nosocomial RVGE among <5-year-olds decreased by 74% (IRR = 0.26; 95% CI: 0.26-0.27), 70% (IRR = 0.30; 95% CI: 0.30-0.31) and 70% (IRR = 0.30; 95% CI: 0.30-0.31), respectively. Incidence of RVGE-outpatient cases in age groups ineligible for RV-vaccination decreased by 38% (IRR 0.62; 95% CI: 0.61-0.63). Compared with the pre-vaccination period, incidence of intussusception in the first year of life decreased by 28% (IRR = 0.73; 95% CI: 0.68-0.79) while at age of the first vaccine-dose (7th-12th week of age) increase in incidence of intussusception was non-significant (IRR = 1.29; 95% CI: 0.93-1.78).

CONCLUSIONS

Routine RV-vaccination is well accepted in Germany. Since implementation of routine RV-vaccination, RVGE significantly decreased in <5-year-olds and in non-vaccinated older age groups through herd protection. The decline of intussusceptions in the first life year suggests a potential vaccination-associated protection against gastrointestinal infections that might trigger intussusceptions. These encouraging results should be communicated to doctors and parents for further improvement of vaccine uptake and protection of more infants.

The health and economic impact of acute gastroenteritis in Belgium, 2010-2014

Acute gastroenteritis (AGE) remains a common condition in both low- and high-income countries. In Belgium, however, there is currently a lack of information on the societal health and economic impact of AGE. We conducted a retrospective study using mortality and cause-of-death data, hospital data, primary care data, health interview survey data and other published data. We estimated the burden of illness during a 5-year period (2010–2014) in Belgium in terms of deaths, patients admitted to hospitals, patients consulting their general practitioner (GP) and cases occurring in the community. We further quantified the health impact in terms of disability-adjusted life years (DALYs) and the economic impact in terms of cost-of-illness estimates. We estimated 343 deaths, 27 707 hospitalised patients, 464 222 GP consultations and 10 058 741 episodes occurring in the community (0.91 cases/person) on average per year. AGE was associated with 11 855 DALYs per year (107 DALY per 100 000 persons). The economic burden was estimated to represent direct costs of €112 million, indirect costs of €927 million (90% of the total costs) and an average total cost of €103 per case and €94 per person. AGE results in a substantial health and economic impact in Belgium, justifying continued mitigation efforts.

Disease burden and seasonal impact of improving rotavirus vaccine coverage in the United States: A modeling study

Background

Prior to vaccine introduction in 2006, rotavirus was the leading cause of severe diarrhea in children under five years of age in the U.S. Vaccination of infants has led to major reductions in disease burden, a shift in the seasonal peak and the emergence of a biennial pattern of disease. However, rotavirus vaccine coverage has remained relatively low (70–75%) compared to other infant immunizations in the U.S. Part of the reason for this lower coverage is that children whose care is provided by family practitioners (FP) have considerably lower probability of being vaccinated compared to those seen be pediatricians (PE). We used a dynamic transmission model to assess the impact of improving rotavirus vaccine coverage by FP and/or PE on rotavirus gastroenteritis (RVGE) incidence and seasonal patterns.

Methods

A deterministic age-structured dynamic model with susceptible, infectious, and recovered compartments (SIRS model) was used to simulate rotavirus transmission and vaccination. We estimated the reduction of RVGE cases by 2 doses of rotavirus vaccine with three vaccination scenarios: (Status Quo: 85% coverage by pediatricians and 45% coverage by family practitioners; Improved FP: 85% coverage by pediatricians and family practitioners; Improved FP+PE: 95% coverage by pediatricians and family practitioners). In addition, we tested the sensitivity of the model to the assumption of random mixing patterns between children visiting pediatricians and children visiting family practitioners.

Results

In this model, higher vaccine coverage provided by family practitioners and pediatricians leads to lower incidence of severe RVGE cases (23% averted in Improved FP and 57% averted in Improved FP+PE compared to Status Quo) including indirect effects. One critical impact of higher total vaccine coverage is the effect on rotavirus epidemic patterns in the U.S.; the biennial rotavirus epidemic patterns shifted to reduced annual epidemic patterns. Additionally, assortative mixing patterns in children visiting pediatricians and family practitioners amplify the impact of increasing vaccine coverage.

Conclusion

Other high-income countries that introduced vaccine have not experienced biennial patterns, like the U.S. Our results suggest that increasing overall vaccine coverage to 85% among infants would lead to an overall reduction in incidence with annual epidemic patterns.

National rotavirus vaccination programme implementation and gastroenteritis presentations: the paediatric emergency medicine perspective

BACKGROUND

Throughout the developed world, the introduction of rotavirus vaccination has led to reductions in the incidence and severity of acute gastroenteritis (AGE) in young children and consequently to reductions in paediatric emergency department (PED) attendances with AGE. Rotavirus vaccination was added to the Irish National Immunisation Schedule in November 2016.

AIMS

To assess the impact of vaccine introduction on citywide PED attendances and hospital admissions with all-cause AGE during rotavirus season.

METHODS

In an observational study, a retrospective search was performed of electronic records in three independent PEDs in Dublin. Weekly presentations and admissions with AGE in the first 30 weeks (gastroenteritis season) of the years 2012-2018 were counted and stratified by age.

RESULTS

Median weekly presentations in 2017-2018, 126 (interquartile range (IQR) 103-165) were significantly lower than in 2012-2016, 160 (IQR 128-214) (p < 0.001). A reduction in presentations was seen across the three hospitals and in those aged less than 5 years. In one PED, median admissions in 2017-2018 were 10 (IQR 7-13) in comparison with nine (IQR 7-13) in 2012-2016, (p = 0.463). The emergency department AGE presentations to hospital ward admission rate was 6.7:1.

CONCLUSION

A reduction in PED presentations with AGE is demonstrated post-rotavirus vaccine introduction into the Irish National Immunisation Schedule. No significant change in paediatric hospital admissions was demonstrated.

Effects of the rotavirus vaccine program across age groups in the United States: analysis of national claims data, 2001-2016

BACKGROUND

The direct effectiveness of infant rotavirus vaccination implemented in 2006 in the United States has been evaluated extensively, however, understanding of population-level vaccine effectiveness (VE) is still incomplete.

METHODS

We analyzed time series data on rotavirus gastroenteritis (RVGE) and all-cause acute gastroenteritis (AGE) hospitalization rates in the United States from the MarketScan® Research Databases for July 2001-June 2016. Individuals were grouped into ages 0-4, 5-9, 10-14, 15-24, 25-44, and 45-64 years. Negative binomial regression models were fitted to monthly RVGE and AGE data to estimate the direct, indirect, overall, and total VE.

RESULTS

A total of 9211 RVGE and 726,528 AGE hospitalizations were analyzed. Children 0-4 years of age had the largest declines in RVGE hospitalizations with direct VE of 87% (95% CI: 83, 90%). Substantial indirect effects were observed across age groups and generally declined in each older group. Overall VE against RVGE hospitalizations for all ages combined was 69% (95% CI: 62, 76%). Total VE was highest among young children; a vaccinated child in the post-vaccine era has a 95% reduced risk of RVGE hospitalization compared to a child in the pre-vaccine era. We observed higher direct VE in odd post-vaccine years and an opposite pattern for indirect VE.

CONCLUSIONS

Vaccine benefits extended to unvaccinated individuals in all age groups, suggesting infants are important drivers of disease transmission across the population. Imperfect disease classification and changing disease incidence may lead to bias in observed direct VE.

TRIAL REGISTRATION

Not applicable.

Equity and impact: Ontario's infant rotavirus immunization program five years following implementation. A population-based cohort study

BACKGROUND

Ontario implemented a publicly-funded rotavirus (RV) immunization program in 2011. Our objectives were to evaluate its impact on hospitalizations and emergency department (ED) visits for acute gastroenteritis (AGE) five years after implementation.

METHODS

We performed a population-based longitudinal retrospective cohort study to identify hospitalizations and ED visits for RV-AGE and overall AGE in all age groups using ICD-10 codes between August 1, 2005 and March 31, 2016. A negative binomial regression model that included the effect of time was used to calculate rates, rate ratios (RRs) and 95% confidence intervals (CIs) for AGE before and after the program's implementation, after adjusting for age, seasonality and secular trends. We examined the seasonality of RV-AGE hospitalizations among children under five before and after the program and explored its equity impact.

RESULTS

Following program implementation, RV-AGE hospitalizations and ED visits among children under five years declined by 76% (RR 0.24, 95% CI 0.20-0.28) and 68% (RR 0.32, 95% CI 0.21-0.50), respectively. In addition, hospitalizations and ED visits for overall AGE declined by 38% (RR 0.62, 95% CI 0.59-0.65) and 26% (RR 0.74, 95% CI 0.73-0.76), respectively, among children under age five. Significant reductions in both outcomes were also found across a range of age-strata. In the pre-program period, the mean monthly hospitalization rate for RV-AGE among children residing in the most marginalized neighbourhoods was 33% higher than those residing in the least marginalized (RR 1.33, 95% CI 1.17-1.52), this disparity was not evident in the program period (RR 0.95, 95% CI 0.69-1.32). We found no evidence of a seasonal shift in rotavirus pediatric hospitalizations.

INTERPRETATION

The introduction of routine infant rotavirus immunization has had a substantial population impact in Ontario. Our study confirms herd effects and suggests the program may have reduced previous inequities in the burden of pediatric rotavirus hospitalizations.

Rotavirus gastroenteritis hospitalization rates and correlation with rotavirus vaccination coverage in Sicily

Background and aim of the works:Rotavirus (RV) is considered the main cause of gastroenteritis in children from 0 to 59 months and vaccination represents the only strategy to prevent hospitalizations due to RV. In 2013 Sicilian Region introduced universal RV vaccination for all newborns. The present study aims to estimate the reduction rotavirus gastroenteritis (RVGE) hospitalization rates among Sicilian children and their relations with vaccination coverages of the nine Sicilian Local Health Units (LHUs). Methods: Were analyzed hospital discharge records including a diagnosis of RVGE occurred from January 2009 to December 2017 in hospitalized children aged 0 to 59 months, residents in Sicily. Were reported data on complete RV vaccination cycles among Sicilian children under 12 months of age (vaccination coverage). Results: A 49.2% overall reduction of RVGE hospitalization rates was reported after RV vaccination introduction. A more considerable reduction of hospitalization rates was observed among children aged 0 to 11 months (-61.4%), followed by children aged 12-23 months (-51.2%) and 24-35 months (-48.8%). In all the nine Sicilian Local Health Units (LHUs), a reduction of RVGE hospitalization rates was observed after RV vaccine implementation. Conclusions: This study demonstrated the significant impact of RV vaccination on RVGE hospitalization rates in Sicily, especially among children aged 0 to 23 months. The reduction in RVGE hospitalization rates observed in the Sicilian LHUs after universal vaccination program implementation, were generally higher or consistent with average vaccination coverage reported from 2013 to 2017. (www.actabiomedica.it)

Updated cost-effectiveness and risk-benefit analysis of two infant rotavirus vaccination strategies in a high-income, low-endemic setting

BACKGROUND AND OBJECTIVE

Since 2013, a biennial rotavirus pattern has emerged in the Netherlands with alternating high and low endemic years and a nearly 50% reduction in rotavirus hospitalization rates overall, while infant rotavirus vaccination has remained below 1% throughout. As the rotavirus vaccination cost-effectiveness and risk-benefit ratio in high-income settings is highly influenced by the total rotavirus disease burden, we re-evaluated two infant vaccination strategies, taking into account this recent change in rotavirus epidemiology.

METHODS

We used updated rotavirus disease burden estimates derived from (active) surveillance to evaluate (1) a targeted strategy with selective vaccination of infants with medical risk conditions (prematurity, low birth weight, or congenital conditions) and (2) universal vaccination including all infants. In addition, we added herd protection as well as vaccine-induced intussusception risk to our previous cost-effectiveness model. An age- and risk-group structured, discrete-time event, stochastic multi-cohort model of the Dutch pediatric population was used to estimate the costs and effects of each vaccination strategy.

RESULTS

The targeted vaccination was cost-saving under all scenarios tested from both the healthcare payer and societal perspective at rotavirus vaccine market prices (€135/child). The cost-effectiveness ratio for universal vaccination was €51,277 at the assumed vaccine price of €75/child, using a societal perspective and 3% discount rates. Universal vaccination became cost-neutral at €32/child. At an assumed vaccine-induced intussusception rate of 1/50,000, an estimated 1707 hospitalizations and 21 fatal rotavirus cases were averted by targeted vaccination per vaccine-induced intussusception case. Applying universal vaccination, an additional 571 hospitalizations and <  1 additional rotavirus death were averted in healthy children per vaccine-induced intussusception case.

CONCLUSION

While universal infant rotavirus vaccination results in the highest reductions in the population burden of rotavirus, targeted vaccination should be considered as a cost-saving alternative with a favorable risk-benefit ratio for high-income settings where universal implementation is unfeasible because of budget restrictions, low rotavirus endemicity, and/or public acceptance.

A benefit-risk analysis of rotavirus vaccination, France, 2015

Two vaccines available for protection against rotavirus gastroenteritis (RVGE), Rotarix and RotaTeq, have contributed to a large decrease in the incidence of paediatric diarrhoea in countries where they have been used. However, they have also led to a small increase in the risk of intussusception. Methods: We compare the number of prevented hospitalisations for RVGE to the number of vaccine-induced hospitalised intussusceptions in France. Results: With 9.5% coverage (French 2015 estimation), vaccination was estimated to prevent, annually, a median of 1,074 hospitalisations (2.5th and 97.5th percentiles (2.5th–97.5th): 810–1,378) and 1.4 deaths (2.5th–97.5th: 1.2–1.6) from RVGE. It was also estimated to cause, annually, 5.0 hospitalisations (2.5th–97.5th: 3.2–7.7) and 0.005 deaths (2.5th–97.5th: 0.001–0.015) from intussusception. The benefit–risk ratio is therefore 214 (2.5th–97.5th: 128–362) for hospitalisations and 273 (2.5th–97.5th: 89–1,228) for deaths. Under a hypothetical 92% coverage, rotavirus vaccination with Rotarix would avoid 10,459 (2.5th–97.5th: 7,702–13,498) hospitalisations for RVGE and induce 47.0 (2.5th–97.5th: 25.1–81.4) hospitalisations for intussusception annually, thereby preventing 13.7 (2.5th–97.5th: 11.1–15.2) deaths and inducing 0.05 (2.5th–97.5th: 0.01–0.15) deaths. Conclusion: The benefit–risk ratio in France is similar to that of other European countries.

Annual changes in rotavirus hospitalization rates before and after rotavirus vaccine implementation in the United States

BACKGROUND

Hospitalizations for rotavirus and acute gastroenteritis (AGE) have declined in the US with rotavirus vaccination, though biennial peaks in incidence in children aged less than 5 years occur. This pattern may be explained by lower rotavirus vaccination coverage in US children (59% to 73% from 2010-2015), resulting in accumulation of susceptible children over two successive birth cohorts.

METHODS

Retrospective cohort analysis of claims data of commercially insured US children aged <5 years. Age-stratified hospitalization rates for rotavirus and for AGE from the 2002-2015 rotavirus seasons were examined. Median age and rotavirus vaccination coverage for biennial rotavirus seasons during pre-vaccine (2002-2005), early post-vaccine (2008-2011) and late post-vaccine (2012-2015) years.

RESULTS

Age-stratified hospitalization rates decreased from pre-vaccine to early post-vaccine and then to late post-vaccine years. The clearest biennial pattern in hospitalization rates is the early post-vaccine period, with higher rates in 2009 and 2011 than in 2008 and 2010. The pattern diminishes in the late post-vaccine period. For rotavirus hospitalizations, the median age and the difference in age between biennial seasons was highest during the early post-vaccine period; these differences were not observed for AGE hospitalizations. There was no significant difference in vaccination coverage between biennial seasons.

CONCLUSIONS

These observations provide conflicting evidence that incomplete vaccine coverage drove the biennial pattern in rotavirus hospitalizations that has emerged with rotavirus vaccination in the US. As this pattern is diminishing with higher vaccine coverage in recent years, further increases in vaccine coverage may reach a threshold that eliminates peak seasons in hospitalizations.

John Snow, Cholera, the Broad Street Pump; Waterborne Diseases Then and Now

Cholera was a major global scourge in the 19^th century, with frequent large-scale epidemics in European cities primarily originating in the Indian subcontinent. John Snow conducted pioneering investigations on cholera epidemics in England and particularly in London in 1854 in which he demonstrated that contaminated water was the key source of the epidemics. His thorough investigation of an epidemic in the Soho district of London led to his conclusion that contaminated water from the Broad Street pump was the source of the disease and, consequently, the removal of the handle led to cessation of the epidemic. He further studied cholera in London homes that were receiving water from two water supply systems; one from the sewage contaminated portion of the Thames River and the other that drew its water upstream from an uncontaminated part of the river. Rates of infection among clients of the distribution system drawing contaminated water far exceeded the, rates among those served by the company whose water intake was from above the contaminated section of the river. This demonstration reinforced the goals of the sanitation movement, which developed sewage drainage systems and water purification systems in cities and towns in the following decades, therewith vastly reducing the threats of cholera, typhoid and many other waterborne diseases. Despite progress being made globally, the public health problems of waterborne disease, including cholera, are by no means gone today, even in high-income countries. The tragic introduction of cholera after the earthquake devastation in Haiti in 2010 resulted in many thousands of cases and deaths from cholera indicating the still-present dangers of diseases spread into disaster situations. Cholera and other waterborne diseases remain some of the heaviest burdens of disease and death in low-income countries, especially after natural disasters or warfare as in Yemen in 2017 and are continuing challenges for global health.

Rotavirus Infection in the Auckland Region After the Implementation of Universal Infant Rotavirus Vaccination: Impact on Hospitalizations and Laboratory Implications

BACKGROUND

In July 2014, New Zealand introduced universal infant vaccination with RotaTeq (Merk & Co.) administered as 3 doses at 6 weeks, 3 and 5 months of age. We sought to assess the impact of rotavirus vaccination on gastroenteritis (GE) hospitalizations in the greater Auckland region and analyze changes in rotavirus testing in the period around vaccine introduction.

METHODS

Hospitalizations, laboratory testing rates and methods were compared between the pre-vaccine period (2009-2013), post-vaccine period (January 2015 to December 2015) and year of vaccine introduction (2014).

RESULTS

There was a 68% decline in rotavirus hospitalizations of children <5 years of age after vaccine introduction (from 258/100,000 to 83/100,000) and a 17% decline in all-cause gastroenteritis admissions (from 1815/100,000 to 1293/100,000). Reductions were also seen in pediatric groups too old to have received vaccine. Despite these changes, rotavirus testing rates in our region remained static in the year after vaccine introduction compared with the 2 prior years, and after vaccine introduction, we observed a high rate of false positives 19/58 (33%) in patients with reactive rotavirus tests.

CONCLUSIONS

Rotavirus vaccine has had a significant early impact on gastroenteritis hospitalizations for children in the Auckland region. However, continued rotavirus testing at pre-vaccine rates risks generating false positive results. Laboratories and clinicians should consider reviewing their testing algorithms before vaccine introduction.

Beyond expectations: Post-implementation data shows rotavirus vaccination is likely cost-saving in Australia

BACKGROUND

Universal vaccination against rotavirus was included in the funded Australian National Immunisation Program in July 2007. Predictive cost-effectiveness models assessed the program before introduction.

METHODS

We conducted a retrospective economic evaluation of the Australian rotavirus program using national level post-implementation data on vaccine uptake, before-after measures of program impact and published estimates of excess intussusception cases. These data were used as inputs into a multi-cohort compartmental model which assigned cost and quality of life estimates to relevant health states, adopting a healthcare payer perspective. The primary outcome was discounted cost per quality adjusted life year gained, including or excluding unspecified acute gastroenteritis (AGE) hospitalisations.

RESULTS

Relative to the baseline period (1997-2006), over the 6years (2007-2012) after implementation of the rotavirus program, we estimated that ∼77,000 hospitalisations (17,000 coded rotavirus and 60,000 unspecified AGE) and ∼3 deaths were prevented, compared with an estimated excess of 78 cases of intussusception. Approximately 90% of hospitalisations prevented were in children <5years, with evidence of herd protection in older age groups. The program was cost-saving when observed changes (declines) in both hospitalisations coded as rotavirus and as unspecified AGE were attributed to the rotavirus vaccine program. The adverse impact of estimated excess cases of intussusception was far outweighed by the benefits of the program.

CONCLUSION

The inclusion of herd impact and declines in unspecified AGE hospitalisations resulted in the value for money achieved by the Australian rotavirus immunisation program being substantially greater than predicted bypre-implementation models, despite the potential increased cases of intussusception. This Australian experience is likely to be relevant to high-income countries yet to implement rotavirus vaccination programs.

Identification of vaccine-derived rotavirus strains in children with acute gastroenteritis in Japan, 2012-2015

Two live attenuated oral rotavirus vaccines, Rotarix and RotaTeq, have been introduced as voluntary vaccination in Japan since 2011 and 2012, respectively. Effectiveness of the vaccines has been confirmed, whereas concerns such as shedding of the vaccine strains and gastroenteritis cases caused by vaccine strains are not well assessed. We aimed to identify the vaccine strains in children with acute gastroenteritis (AGE) to investigate the prevalence of AGE caused by vaccination or horizontal transmission of vaccine strains. A total of 1,824 stool samples were collected from children with AGE at six outpatient clinics in 2012-2015. Among all, 372 group A rotavirus (RVA) positive samples were screened for vaccine components by real-time RT-PCR which were designed to differentiate vaccine strains from rotavirus wild-type strains with high specificity. For samples possessing both vaccine and wild-type strains, analyses by next-generation sequencing (NGS) were conducted to characterize viruses existed in the intestine. As a result, Rotarix-derived strains were identified in 6 of 372 (1.6%) RVA positive samples whereas no RotaTeq strain was detected. Among six samples, four possessed Rotarix-derived strains while two possessed both Rotarix-derived strains and wild-type strains. In addition, other pathogens such as norovirus, enterovirus and E.coli were detected in four samples. The contribution of these vaccine strains to each patient's symptoms was unclear as all of the cases were vaccinated 2-14 days before sample collection. Proportion of average coverage for each segmented gene by NGS strongly suggested the concurrent infection of the vaccine-derived strain and the wild-type strain rather than reassortment of these two strains in one sample. This is the first study to report the prevalence of vaccine-derived strains in patients with RVA AGE in Japan as 1.6% without evidence of horizontal transmission. The results emphasized the importance of continuous monitoring on vaccine strains and their clinical impacts on children.

Parents' insights after pediatric hospitalization due to rotavirus gastroenteritis in Italy

Most of the severe cases of acute gastroenteritis in infants and children under 5 globally are caused by rotavirus infection. There are nearly 15,000 rotavirus gastroenteritis (RVGE) hospitalizations in Italy each year, which could be reduced by available rotavirus vaccines. In addition to the economic and societal burden, RVGE hospitalization could impact families negatively. The aim of this survey was to obtain parents' insights after hospitalization of their child for RVGE. Parents, of 500 children aged 0–5 years, were interviewed about their experience of RVGE hospitalization and asked to rate their stress on different items and overall. Most children (32.6%) were hospitalized aged 12–23 months, and 6.8% were <6 months old. Family pediatricians referred 56.2% of cases to hospital, and 25.8% went based on their parents' decision. During hospitalization, mean parental stress scores (out of 10, with 10 as highest stress) ranged from 6.6 to 8.4. The highest scores were for child malaise (8.42, SD 1.00), vomiting/diarrhea (8.07, SD 0.97), stress for the family in general (7.82, SD 0.90), parental stress (7.68, SD 0.93) and child dehydration (7.18, SD 1.02). The overall stress for the family was graded as ‘high' by 67.2% of parents.

Geographical areas and stress level were related (p = 0.0071), being the “high” stress score not an evenly distributed variable (p < 0.0001). Most children (91.8%) were not vaccinated against rotavirus, as most parents (74.5%) were not aware of vaccination availability. Parental distress due to RVGE hospitalization appears to be significant (93.6% reporting high/medium stress) and there is an important lack of awareness among parents about rotavirus vaccination. More education on RVGE for families in Italy should be warranted.

Public Health Surveillance Systems: Recent Advances in Their Use and Evaluation

Surveillance is critical for improving population health. Public health surveillance systems generate information that drives action, and the data must be of sufficient quality and with a resolution and timeliness that matches objectives. In the context of scientific advances in public health surveillance, changing health care and public health environments, and rapidly evolving technologies, the aim of this article is to review public health surveillance systems. We consider their current use to increase the efficiency and effectiveness of the public health system, the role of system stakeholders, the analysis and interpretation of surveillance data, approaches to system monitoring and evaluation, and opportunities for future advances in terms of increased scientific rigor, outcomes-focused research, and health informatics.

Rotavirus immunization: Global coverage and local barriers for implementation

BACKGROUND

Rotavirus (RV) is a major agent of gastroenteritis and an important cause of child death worldwide. Immunization (RVI) has been available since 2006, and the Federation of International Societies of Gastroenterology Hepatology and Nutrition (FISPGHAN) identified RVI as a top priority for the control of diarrheal illness. A FISPGHAN working group on acute diarrhea aimed at estimating the current RVI coverage worldwide and identifying barriers to implementation at local level.

METHODS

A survey was distributed to national experts in infectious diseases and health-care authorities (March 2015-April 2016), collecting information on local recommendations, costs and perception of barriers for implementation.

RESULTS

Forty-nine of the 79 contacted countries (62% response rate) provided a complete analyzable data. RVI was recommended in 27/49 countries (55%). Although five countries have recommended RVI since 2006, a large number (16, 33%) included RVI in a National Immunization Schedule between 2012 and 2014. The costs of vaccination are covered by the government (39%), by the GAVI Alliance (10%) or public and private insurance (8%) in some countries. However, in most cases, immunization is paid by families (43%). Elevated cost of vaccine (49%) is the main barrier for implementation of RVI. High costs of vaccination (rs=-0.39, p=0.02) and coverage of expenses by families (rs=0.5, p=0.002) significantly correlate with a lower immunization rate. Limited perception of RV illness severity by the families (47%), public-health authorities (37%) or physicians (24%) and the timing of administration (16%) are further major barriers to large- scale RVI programs.

CONCLUSIONS

After 10years since its introduction, the implementation of RVI is still unacceptably low and should remain a major target for global public health. Barriers to implementation vary according to setting. Nevertheless, public health authorities should promote education for caregivers and health-care providers and interact with local health authorities in order to implement RVI.

Assessing the sensitivity and representativeness of the Belgian Sentinel Network of Laboratories using test reimbursement data

BACKGROUND

The Belgian Sentinel Network of Laboratories (SNL) was created in 1983 in order to monitor trends in infectious diseases. Given the evolution of the surveillance system, such as the waivers, fusions and adhesions of laboratories over time, it is important to evaluate whether the SNL is still fit for purpose. This study aims to evaluate aspects of the sensitivity and representativeness of the SNL by means of a test coverage analysis.

METHODS

We estimated test coverage of the SNL using the ratio of reimbursed tests performed by participating laboratories to the total number of tests performed between 2007 and 2012, for 12 (groups of) pathogens. We further evaluated the geographical difference coverage of the SNL at regional and provincial levels.

RESULTS

We found that test coverage of the SNL was stable over time and close to, or greater than, 50 % for the 12 (groups of) pathogens studied. These results hold for the three regions of Belgium but not for all provinces. We showed that some provinces had a low test coverage for some pathogens and that test coverage was more variable over time at provincial level.

CONCLUSIONS

This sensitivity and representativeness study based on test coverage suggests that the SNL is capable to describe trend and to monitor changes in the 12 (groups of) pathogens studied both at national and regional levels. Therefore, the SNL is useful to contribute to estimate the burden of disease and to inform preventive measures. It should however be reinforced to allow to be used as an alert system at provincial level.

Did Large-Scale Vaccination Drive Changes in the Circulating Rotavirus Population in Belgium?

Vaccination can place selective pressures on viral populations, leading to changes in the distribution of strains as viruses evolve to escape immunity from the vaccine. Vaccine-driven strain replacement is a major concern after nationwide rotavirus vaccine introductions. However, the distribution of the predominant rotavirus genotypes varies from year to year in the absence of vaccination, making it difficult to determine what changes can be attributed to the vaccines. To gain insight in the underlying dynamics driving changes in the rotavirus population, we fitted a hierarchy of mathematical models to national and local genotype-specific hospitalization data from Belgium, where large-scale vaccination was introduced in 2006. We estimated that natural- and vaccine-derived immunity was strongest against completely homotypic strains and weakest against fully heterotypic strains, with an intermediate immunity amongst partially heterotypic strains. The predominance of G2P[4] infections in Belgium after vaccine introduction can be explained by a combination of natural genotype fluctuations and weaker natural and vaccine-induced immunity against infection with strains heterotypic to the vaccine, in the absence of significant variation in strain-specific vaccine effectiveness against disease. However, the incidence of rotavirus gastroenteritis is predicted to remain low despite vaccine-driven changes in the distribution of genotypes.