Vaccine Take of RV3-BB Rotavirus Vaccine Observed in Indonesian Infants Regardless of HBGA Status

BACKGROUND

Histo-blood group antigen (HBGA) status may affect vaccine efficacy due to rotavirus strains binding to HBGAs in a P genotype-dependent manner. This study aimed to determine if HBGA status affected vaccine take of the G3P[6] neonatal vaccine RV3-BB.

METHODS

DNA was extracted from stool samples collected in a subset (n = 164) of the RV3-BB phase IIb trial in Indonesian infants. FUT2 and FUT3 genes were amplified and sequenced, with any single-nucleotide polymorphisms analyzed to infer Lewis and secretor status. Measures of positive cumulative vaccine take were defined as serum immune response (immunoglobulin A or serum-neutralizing antibody) and/or stool excretion of RV3-BB virus. Participants were stratified by HBGA status and measures of vaccine take.

RESULTS

In 147 of 164 participants, Lewis and secretor phenotype were determined. Positive vaccine take was recorded for 144 (97.9%) of 147 participants with the combined phenotype determined. Cumulative vaccine take was not significantly associated with secretor status (relative risk, 1.00 [95% CI, .94-1.06]; P = .97) or Lewis phenotype (relative risk, 1.03 [95% CI, .94-1.14]; P = .33), nor was a difference observed when analyzed by each component of vaccine take.

CONCLUSIONS

The RV3-BB vaccine produced positive cumulative vaccine take, irrespective of HBGA status in Indonesian infants.

Maternal knowledge and attitudes towards rotavirus diarrhea and vaccine acceptance in Yogyakarta, Indonesia: a qualitative study

Abstract Background Rotavirus is a leading cause of hospitalized diarrhea cases in Indonesia. Despite the rotavirus vaccine being recommended by the Indonesian Pediatric Society since 2011, it has yet to be been included in the Indonesian national immunization program (NIP) schedule. Objective To explore maternal knowledge of and attitudes towards rotavirus diarrhea, as well as barriers to vaccine acceptance in Yogyakarta, Indonesia. Methods We conducted 26 in-depth interviews in two districts (rural and urban areas) of Yogyakarta Province, Indonesia. Participants included women in their third trimester of pregnancy and mothers of infants younger than 14 weeks. We then proceeded with thematic analysis. Results Participants did not perceive diarrhea as being a priority health problem. Very few had heard of rotavirus diarrhea or were aware of vaccine availability. While participants would accept vaccinating their children against rotavirus, some key barriers impacted vaccine use. As the rotavirus vaccine is not included in the Indonesian NIP, parents perceived it as not essential. Parents were concerned about the safety and benefit of the vaccine due to its perceived newness. Other concerns were cost and halal status. Participants expressed a need for more information on the vaccine's effectiveness and safety, with their primary healthcare providers (HCPs) considered to play the most important role in vaccine acceptance. Conclusions In Yogyakarta, Indonesia, awareness of the seriousness of rotavirus disease and the availability of the rotavirus vaccine is low. Its newness, safety, efficacy, and cost, and doubts about its halal status, were barriers to vaccine acceptance. Information and recommendations from HCPs play an essential role in vaccine acceptance.

Intermittent screening and treatment for malaria complementary to routine immunisation in the first year of life in Papua, Indonesia: a cluster randomised superiority trial

BACKGROUND

In Papua (Indonesia), infants with P. falciparum and/or P. vivax malaria are at risk of severe anaemia and death. We hypothesized that in an area of high malaria transmission, intermittent screening and treatment of infants with malaria (ISTi) will reduce morbidity compared to passive case detection (PCDi).

METHODS

We conducted a cluster randomised, open label, superiority trial. A total of 21 clusters of village health posts (VHP) were randomised 1:1 to either IST for infants coinciding with 4 routine immunisation visits or PCDi. Healthy term infants born to consenting mothers enrolled into a maternal malaria cluster randomised trial were included in the study and followed for 12 months. Point of care malaria rapid diagnostic tests were used to detect peripheral parasitaemia at 2, 3, 4 and 9 months old in all infants in ISTi clusters and when symptomatic in PCDi clusters. Infants with detected peripheral parasitaemia were treated with dihydroartemisinin-piperaquine. The co-primary outcomes were the incidence rate of clinical malaria in the first year of life and the prevalence of parasitaemia at age 12 months. The incidence rate ratio and prevalence ratio between ISTi and PCDi were estimated using mixed-effects Poisson and log-binomial regression modelling (accounting for clustering at VHP level).

RESULTS

Between May 2014 and February 2017, 757 infants were enrolled into the study, 313 into 10 ISTi clusters, and 444 into 11 PCDi clusters. Overall, 132 episodes of parasitaemia were detected, of whom 17 (12.9%) were in symptomatic infants. Over 12 months, the incidence rate (IR) of clinical malaria was 24 [95% CI, 10-50] per 1000 children-years at risk in the ISTi arm and 19 [95% CI, 8,38] per 1000 children-years in the PCDi arm (adjusted incidence rate ratio [aIRR] 1.77 [95% CI, 0.62-5.01]; p = 0.280). The prevalence of parasitaemia at 12 months was 13% (33/254) in the IST clusters and 15% (57/379) in the PCD clusters (adjusted prevalence ratio (aPR) = 0.92 (95% CI, 0.70-1.21), p = 0.55). There was no difference in the risk of anaemia between treatment arms.

CONCLUSIONS

In high malaria transmission area outside of Africa, our study suggests that compared to PCDi, ISTi offers no significant benefit in reducing the risk of clinical malaria in infants born to women receiving effective protection from malaria during pregnancy.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02001428 , registered on 20 Nov 2013.

Risk factors for healthcare-associated infection among children in a low-and middle-income country

BACKGROUND

Healthcare-associated infections (HAI) are one of significant causes of morbidity and mortality. Evaluating risk factors associated with HAI are important to improve clinical outcomes. We aimed to evaluate the risk factors of HAI in children in a low-to middle-income country.

METHODS

A prospective cohort study was conducted during 43 months at a teaching hospital in Yogyakarta, Indonesia. All consecutive patients admitted to pediatric ICU and pediatric wards > 48 h were eligible. Those eligible patients were observed daily to identify the presence of HAI based on CDC criteria. The risk factors of HAI were identified. Multivariable logistic regression was used to identify independent risk factors.

RESULTS

Total of 2612 patients were recruited. Of 467 were diagnosed as HAI. The cumulative incidence of HAI was 17.9%. In the multivariable analysis; length of stay > 7 days, severe sepsis, use of urine catheter, central venous catheter (CVC), non-standardized antibiotics, and aged < 1 year were independently associated with increased risk of HAI with adjusted OR (95%CI): 5.6 (4.3-7.3), 1.9 (1.3-2.9), 1.9 (1.3-2.6), 1.8 (1.1-2.9), 1.6 (1.2-2.0), and 1.4 (1.1-1.8), respectively.

CONCLUSIONS

This study found that length of stay > 7 days, use of urine catheter and CVC, non-standardized antibiotic use, aged < 1 year, and had a diagnosis of severe sepsis increased risk of HAI.

Direct and indirect costs of acute diarrhea in children under five years of age in Indonesia: Health facilities and community survey

BACKGROUND

Diarrhea remains a major cause of child morbidity and mortality in low- and middle-income countries. Reliable data on the economic burden of diarrhea is required to support the selection of appropriate health intervention programs. This study aimed to estimate the costs of acute diarrhea in children under five years of age in Indonesia, a large middle-income country with a substantial diarrheal burden.

METHODS

Direct medical cost data were extracted retrospectively for 1050 children under five years of age with acute diarrhea receiving inpatient care across 45 health facilities in seven Indonesian provinces during 2017-2020. Direct medical costs for children treated in outpatient settings were estimated by collecting unit costs associated with standard diarrhea case management in children. A structured interview of 240 caregivers of inpatients was also conducted retrospectively to estimate direct non-medical costs as well as indirect costs from caregiver income loss.

RESULTS

The weighted average direct medical cost for treatment of acute diarrhea as an inpatient and outpatient across health facility types was US$99.8 (SD±$56.8)(35% room costs, 29% professional fees, 26% medication costs, 10% diagnostic costs) and US$7.6 (SD±$4.3) (34% diagnostic costs, 28% medication costs, 27% professional fees, 10% registration fees), respectively. The average direct non-medical household cost for an acute diarrheal admission was US$4.90 and the indirect cost was US$9.90.

CONCLUSION

There is a significant economic burden associated with acute diarrhea in children in Indonesia. This study, based on a wide variety of health care settings and geographical regions, provides data to inform the economic evaluation of rotavirus vaccines and other diarrheal prevention programs.

FUNDING

This work was supported by a research grant from the Murdoch Children's Research Institute (MCRI) and PATH; and the Indonesian Technical Advisory Group on Immunization (ITAGI).

Predictive Factors for Cardiopulmonary Resuscitation Failure

Objectives

Patients with chronic diseases are often admitted to the hospital through the emergency room of the hospital because of complaints of dyspnoea, urinary retention, decreased consciousness and cardiac arrest requiring resuscitation. The purpose of this study is to find predictive factors for failure of cardiopulmonary resuscitation (CPR) in patients of chronic diseases.

Materials and Methods

This cross-sectional study took medical records of patients who were carried out from primary healthcare center in Yogyakarta from 2017 to 2019. Bivariate statistical analysis used Fisher's exact test to determine the relative risk; if P < 0.25, then multivariate analysis with logistic regression continued with the backward method to obtain the odds ratio (OR).

Results

The results indicate that cardiac arrest patients with sepsis are most likely to fail at CPR, whereas male patients are 9.1 times (OR 9.1); patients with acidosis, 8.1 times (OR 8.1); and patients with asystole heart rhythm, 7.8 times (OR 7.8, P < 0.05). We can conclude that male patients with sepsis, acidosis or asystole heart rhythm will almost certainly fail to receive resuscitation.

Conclusion

Sepsis or septic shock, the male gender, acidosis, and asystole rhythm can be determinants of mortality in patients with chronic diseases who undergo CPR. It is necessary for one to test the application of the checklist or data from other hospitals and score the predictive factors to make the determination of the success of CPR easier.

Vitamin D deficiency and severity of pneumonia in Indonesian children

Objective

To determine the prevalence of vitamin D deficiency in Indonesian children hospitalized with pneumonia and evaluate the association between vitamin D status and severity of pneumonia.

Methods

A hospital-based cross-sectional study was conducted from February 2016 to July 2017 in two district hospitals in Yogyakarta province, Indonesia. Infants and young children aged 2–59 months hospitalized with pneumonia were recruited. Serum blood samples were collected on admission and analyzed for total serum 25-hydroxyvitamin D3 and 25-hydroxyvitamin D2 concentrations using liquid chromatography-tandem mass spectrometry. Vitamin D deficiency was defined as a level of serum vitamin D <50 nmol/L. The association between vitamin D deficiency and severity of hospitalized pneumonia according to WHO criteria, including the presence of danger signs, hypoxemia (SpO2 in air below 90%), duration of hospitalization, and admission to Intensive Care Unit (ICU), was analyzed using logistic regression.

Results

133 children with WHO-defined pneumonia were enrolled in the study and 127 (96%) had their vitamin D status determined. The mean vitamin D concentration was 67 (± 24 SD) nmol/L and 19% of participants were vitamin D deficient. Age younger than 6 months was associated with prolonged hospitalization (> 5 days) and low birth weight and poor nutritional status on admission were risk factors for hypoxemia. However, vitamin D status was not associated with the presence of danger signs, duration of hospitalization, or hypoxemia.

Conclusions

One in every five children hospitalized with pneumonia was vitamin D deficient. Vitamin D status was not associated with the severity of pneumonia.

Safety and immunogenicity of human neonatal RV3 rotavirus vaccine (Bio Farma) in adults, children, and neonates in Indonesia: Phase I Trial

BACKGROUND

Despite safe and effective WHO prequalified rotavirus vaccines, at least 84 million children remain unvaccinated. A birth dose schedule of the RV3-BB vaccine was reported to be highly efficacious against severe rotavirus disease in Indonesian infants and is under further development at PT Bio Farma, Indonesia. The aim is to develop a rotavirus vaccine starting from birth that could improve the implementation, safety, and effectiveness of vaccines.

METHODS

A multi-site phase I study of a human neonatal RV3 rotavirus vaccine (Bio Farma) in adults, children, neonates in Indonesia from April 2018 to March 2019. The adult and child cohorts were open-labeled single-dose, while the neonatal cohort was randomized, double-blind, and placebo-controlled three-doses at the age of 0-5 days, 8-10 weeks, and 12-14 weeks. The primary objective was to assess the safety of vaccines with the immunogenicity and vaccine virus fecal shedding as the secondary endpoints in neonates.

RESULTS

Twenty-five adults, 25 children, and 50 neonates were recruited, and all but one in the neonatal cohort completed all study procedures. Three serious adverse events were reported (1 adult & 2 neonates), but none were assessed related to investigational product (IP). The neonatal vaccine group had a significantly higher positive immune response (cumulative seroconverted SNA and IgA) 28 days after three doses than those in the placebo group (72% vs. 16.7%, respectively). The GMT of serum IgA in the vaccine group was significantly higher at post IP dose 1 (p < 0.05) and post IP dose 3 (p < 0.001) compared to the placebo group.

CONCLUSION

The trial results show that the RV3 rotavirus vaccine (Bio Farma) is well tolerated in all participant cohorts (adults, children, and neonates). Three doses of this vaccine administered in a neonatal schedule were immunogenic. These promising results support further clinical development of the RV3 rotavirus vaccine (Bio Farma).

The incidence of acute respiratory infection in Indonesian infants and association with vitamin D deficiency

Background

Vitamin D deficiency has been associated with acute respiratory infection (ARI) in early life, but this has not been evaluated in Indonesia. We aimed to determine the incidence of ARI in Indonesian infants, and to evaluate the association with vitamin D deficiency.

Methods

From 23 December 2015 to 31 December 2017, we conducted a community-based prospective cohort study in Yogyakarta province. We enrolled 422 pregnant women and followed their infants from birth until 12 months of age for ARI episodes. Vitamin D status was measured at birth and at age six months. We performed Cox proportional hazard regression analysis to evaluate the association between vitamin D deficiency and pneumonia incidence.

Results

At study completion, 95% (400/422) of infants retained with a total of 412 child years of observation (CYO). The incidence of all ARI and of WHO-defined pneumonia was 3.89 (95% CI 3.70–4.08) and 0.25 (95% CI 0.21–0.30) episodes per CYO respectively. Vitamin D deficiency at birth was common (90%, 308/344) and associated with more frequent episodes of ARI non-pneumonia (adjusted odds ratio 4.48, 95% CI:1.04–19.34). Vitamin D status at birth or six months was not associated with subsequent pneumonia incidence, but greater maternal sun exposure during pregnancy was associated with a trend to less frequent ARI and pneumonia in infants.

Conclusion

ARI, pneumonia, and vitamin D deficiency at birth were common in Indonesian infants. Minimising vitamin D deficiency at birth such as by supplementation of mothers or safe sun exposure during pregnancy has the potential to reduce ARI incidence in infants in this setting.

Non-antibiotic medication use in an Indonesian community cohort 0-18 months of age

BACKGROUND

Rational medication use for treatment is mandatory, particularly in children as they are vulnerable to possible hazards of drugs. Understanding the medication use pattern is of importance to identify the problems of drug therapy and to improve the appropriate use of medication among this population.

METHODS

A post-hoc study of the RV3-BB Phase IIb trial to children aged 0-18 months which was conducted in Indonesia during January 2013 to July 2016. Any concomitant medication use and health events among 1621 trial participants during the 18 months of follow-up were documented. Information on medication use included the frequency, formulation, indication, duration of usage, number of regimens, medication types, and therapeutic classes.

RESULTS

The majority of participants (N = 1333/1621; 82.2%) used at least one non-antibiotic medication for treatment during the 18-month observation period. A total of 7586 medication uses were recorded, mostly in oral formulation (90.5%). Of all illnesses recorded, 24.7% were treated with a single drug regimen of non-antibiotic medication. The most common therapeutic classes used were analgesics/antipyretics (30.1%), antihistamines for systemic use (17.4%), cough and cold preparations (13.5%), vitamins (8.6%), and antidiarrheals (6.6%). The main medication types used were paracetamol (29.9%), chlorpheniramine (16.8%), guaifenesin (8.9%), zinc (4.6%), and ambroxol (4.1%). Respiratory system disorder was the most common reason for medication use (51.9%), followed by gastrointestinal disorders (19.2%), pyrexia (16.9%), and skin disorders (7.0%).

CONCLUSION

A large number of children were exposed to at least one medication during their early life, including those where evidence of efficacy and safety in a pediatric population is lacking. This supports the need for further research on pediatric drug therapy to improve the appropriate use of medication in this population.

The prevalence and determinants of vitamin D deficiency in Indonesian infants at birth and six months of age

Background

Vitamin D deficiency in infants has been associated with an increased risk of a number of diseases but there are limited data on the prevalence and determinants of vitamin D deficiency from tropical settings with high infant morbidity and mortality.

Objective

To determine the prevalence and determinants of vitamin D deficiency in infants at birth and at six months of age in Yogyakarta province, Indonesia.

Design

Serum vitamin D of eligible infants was measured in cord blood at birth and at six months of age. Factors associated with vitamin D deficiency (serum 25-hydroxyvitamin D <50 nmol/L) were collected prospectively monthly from birth and concentrations measured by liquid chromatography-tandem mass spectrometry. Independent risk factors were identified by multiple logistic regression.

Results

Between December 2015 to December 2017, 350 maternal-newborn participants were recruited and followed up. Vitamin D deficiency was detected in 90% (308/344) of cord blood samples and 13% (33/255) of venous blood samples at six months. Longer time outdoors (≥2 hours per day) and maternal multivitamin intake containing vitamin D during pregnancy were protective against vitamin D deficiency at birth (AOR: 0.10, 95% CI: 0.01–0.90 and AOR: 0.21, 95% CI: 0.06–0.68, respectively). Risk factors for vitamin D deficiency at six months included lower cumulative skin-sun exposure score (AOR: 1.12, 95% CI: 1.04–1.20), severe vitamin D deficiency at birth (AOR: 7.73, 95% CI: 1.20–49.60) and exclusive breastfeeding (AOR: 2.64, 95% CI: 1.07–6.49) until six months. Among exclusively breast fed (EBF) infants, a higher skin-sun exposure score was associated with reduced vitamin D deficiency risk.

Conclusion

In equatorial regions, the role of ‘safe’ morning sun exposure in infants and mothers in populations with medium to dark brown skin pigmentation and effective interventions to prevent vitamin D deficiency in newborns and EBF infants, need further consideration and evaluation.

Immunogenicity of four doses of oral poliovirus vaccine when co-administered with the human neonatal rotavirus vaccine (RV3-BB)

BACKGROUND

The RV3-BB human neonatal rotavirus vaccine was developed to provide protection from severe rotavirus disease from birth. The aim of this study was to investigate the potential for mutual interference in the immunogenicity of oral polio vaccine (OPV) and RV3-BB.

METHODS

A randomized, placebo-controlled trial involving 1649 participants was conducted from January 2013 to July 2016 in Central Java and Yogyakarta, Indonesia. Participants received three doses of oral RV3-BB, with the first dose given at 0-5 days (neonatal schedule) or ~8 weeks (infant schedule), or placebo. Two sub-studies assessed the immunogenicity of RV3-BB when co-administered with either trivalent OPV (OPV group, n = 282) or inactivated polio vaccine (IPV group, n = 333). Serum samples were tested for antibodies to poliovirus strains 1, 2 and 3 by neutralization assays following doses 1 and 4 of OPV.

RESULTS

Sero-protective rates to poliovirus type 1, 2 or 3 were similar (range 0.96-1.00) after four doses of OPV co-administered with RV3-BB compared with placebo. Serum IgA responses to RV3-BB were similar when co-administered with either OPV or IPV (difference in proportions OPV vs IPV: sIgA responses; neonatal schedule 0.01, 95% CI -0.12 to 0.14; p = 0.847; infant schedule -0.10, 95% CI -0.21 to -0.001; p = 0.046: sIgA GMT ratio: neonatal schedule 1.23, 95% CI 0.71-2.14, p = 0.463 or infant schedule 1.20, 95% CI 0.74-1.96, p = 0.448).

CONCLUSIONS

The co-administration of OPV with RV3-BB rotavirus vaccine in a birth dose strategy did not reduce the immunogenicity of either vaccine. These findings support the use of a neonatal RV3-BB vaccine where either OPV or IPV is used in the routine vaccination schedule.

The effect of zinc supplementation on pro-inflammatory cytokines (TNF-α, IL-1 AND IL-6) in mice with Escherichia coli LPS-induced diarrhea

BACKGROUND AND OBJECTIVES

Inflammation in the intestine causes diarrhea due to an increased release of pro-inflammatory cytokines such as TNF-α, IL-1, and IL-6. These are triggered by the exposure of E. coli-LPS to epithelial cells of the intestinal mucosa as well as low concentration of zinc in plasma such as in infants or children who are experiencing diarrhea. This paper aims to determine the effects of zinc supplementation on pro-inflammatory cytokines (TNF-α, IL-1 and IL-6) in mice with E. coli-LPS-induced diarrhea.

MATERIALS AND METHODS

This study used a controlled trial experimental design in the laboratory. A sample size of 20 mice were randomly divided into 4 groups: 1) Control group was given standard foods, 2) Trial group was given E. coli-LPS 2.5 mg/kg/oral once on day1, 3) Prevention group was given E. coli-LPS + 30 mg/kg/oral of zinc once daily for 12 days, 4) Therapeutic group was given E. coli-LPS, and were then given 30 mg/kg/oral of zinc once daily for 12 days if diarrhea occurred. Blood samples of mice were taken through the orbital sinus on the 0, 5^th, 10^th hour, and on the 4^th, 8^th and 12^th days.

RESULTS

Positive effects of zinc supplementation on levels of pro-inflammatory cytokines were observed, in which the higher levels of zinc were present, the lower levels of pro-inflammatory cytokines, especially TNF-α were observed. However, there was an increase of IL-1 and IL-6 levels on the 8^th day in the prevention and therapeutic groups.

CONCLUSION

Oral zinc supplementation had a significant positive effect on the levels of pro-inflammatory cytokines. Where there were higher levels of zinc, lower levels of pro-inflammatory cytokines TNF-α were present.

Comparison between 200 ml and 1 liter packages of oral rehydration solution prepared by mothers of patients with diarrhea in the oral rehydration room

To have a comparison between the preparation of oral rehydration solution (ORS) of 200 ml and 1 liter packages, a study had been done in 30 mothers of children under five years of age suffering from diarrhea who treated their children in oral rehydration room (group I) and 30 mothers of non diarrheal children under five years sampled in the out-patient Department of Child Health, Dr. Sardjito General Hospital (group II). No significant difference was found (p <0.05) concerning the sodium concentration in th ORS of 200 ml and in the 1 liter package (group I: 85.95 ± 16.07, and 81.52 ± 16.21, group II 98.11 ± 24.67 and 97.02 ± 21.87) (mEq/L, Mean ± SD). Of 30 mothers group 11, 5 mothers (19.23%) made mistakes in preparing the I liter packages of ORS and the sodium concentration in this package was higher compared to the concentration in the 200 ml package. There was no significant difference concerning diluted volume and the sodium concentration between group I and the recommended method, but there was a significant difference (p < 0.005) between group II and recommended method. A significant difference was also found (p ( 0.001) between group I and group 11 about the mothers knowledge of the effect of diarrhea, the use of ORS, the amount of ORS that must be given lo !he patients and !he indications to refer the patients to !he health center or hospital.

Phylogenetic and immunoinformatic analysis of VP4, VP7, and NSP4 genes of rotavirus strains circulating in children with acute gastroenteritis in Indonesia

Rotavirus is a major cause of diarrhea in Indonesian children. However, rotavirus vaccines have not been introduced in the national immunization program of Indonesia. Understanding the genetic diversity and conserved antigenic regions of circulating strains are therefore essential to assess the potential efficacy of rotavirus vaccines. We collected fecal samples from hospitalized children less than 5 years of age with acute diarrhea. Rotavirus genotyping was performed by reverse transcriptase polymerase chain reaction, followed by sequencing of the VP4, VP7, and NSP4 genes of representative strains. Phylogenetic analysis was performed to investigate their relationship with globally circulating strains. Conservational analysis, immunoinformatics, and epitope mapping in comparison to vaccine strains were also performed. The sequence analyses showed that differences of multiple amino acid residues existed between the VP4, VP7, and NSP4 antigenic regions of the vaccine strains and the Indonesian isolates. However, many predicted conserved epitopes with higher antigenicity were observed in the vaccine and Indonesian strains, conferring the importance of these epitopes. The identified epitopes showed a higher potential of rotavirus vaccine to be employed in Indonesia. It could also be helpful to inform the design of a peptide vaccine based on the conserved regions and epitopes in the viral proteins.

Predictors of mortality in children with nosocomial bloodstream infection

Background: Nosocomial bloodstream infection (BSI) is associated with high mortality rates. Evaluating factors to predict mortality is important for prevention and improving clinical outcomes. Aim: To evaluate the clinical predictors of mortality in paediatric nosocomial bloodstream infection. Methods: A prospective cohort study was conducted from 1 December 2010 until 28 February 2013 in a teaching hospital in Yogyakarta, Indonesia. All patients admitted consecutively to the paediatric ICU (PICU) and paediatric wards after > 48 h of hospitalisation were eligible. Patients were observed daily to identify the presence of nosocomial BSI based on Centers for Disease Control and Prevention (CDC) criteria. Patients were followed up until they were discharged or died, and predictors of mortality were identified. Logistic regression was used to identify independent predictors. Results: A total of 2646 patients were recruited, 170 developed nosocomial BSI (6.4%) and 70 of these children died (case fatality rate 41%). Nosocomial BSI was associated with increased mortality with an adjusted OR of 8.5 (95% CI 6.0-12.1). In multivariate analysis, malnutrition, admission to the PICU and use of a central line catheter were independently associated with an increased risk of death with adjusted ORs (95% CI), respectively, of 6.0 (1.6-22.6), 3.2 (1.6-6.7) and 3.1 (1.1-8.7). Conclusion: The study demonstrates that significant mortality is attributable to nosocomial bloodstream infection. An increased risk of death in children with nosocomial BSI can be identified by simple clinical predictors including malnutrition, admission to the PICU and use of a central line catheter.

Religious and community leaders' acceptance of rotavirus vaccine introduction in Yogyakarta, Indonesia: a qualitative study

BACKGROUND

In Indonesia, oral rotavirus vaccines are available but not funded on the National Immunization Program (NIP). New immunization program introduction requires an assessment of community acceptance. For religiously observant Muslims in Indonesia, vaccine acceptance is further complicated by the use of porcine trypsin during manufacturing and the absence of halal labeling. In Indonesia, religious and community leaders and the Majelis Ulama Indonesia (MUI) are important resources for many religiously observant Muslims in decisions regarding the use of medicines, including vaccines. This study aimed to explore the views of religious and community leaders regarding the rotavirus vaccine to inform future communication strategies.

METHODS

Twenty semi-structured in-depth interviews were undertaken with religious leaders and community representatives from two districts of Yogyakarta Province, Indonesia. Thematic analysis was undertaken.

RESULTS

Although there was recognition childhood diarrhoea can be severe and a vaccine was needed, few were aware of the vaccine. Participants believed a halal label was required for community acceptance, and maintenance of trust in their government and leaders. Participants considered themselves to be key players in promoting the vaccine to the community post-labeling.

CONCLUSIONS

This study highlights the need for better stakeholder engagement prior to vaccine availability and the potentially important role of religious and community leaders in rotavirus vaccine acceptability in the majority Muslim community of Yogyakarta, Indonesia. These findings will assist with the development of strategies for new vaccine introduction in Indonesia.

Norovirus and rotavirus infections in children less than five years of age hospitalized with acute gastroenteritis in Indonesia

Rotaviruses and noroviruses are the most important viral causes of acute gastroenteritis in children. While previous studies of acute gastroenteritis in Indonesia mainly focused on rotavirus, here, we investigated the burden and epidemiology of norovirus and rotavirus disease. Children less than five years of age hospitalized with acute gastroenteritis were enrolled in this study from January to December 2015 at three participating hospitals. Rotavirus was detected by enzyme immunoassay (EIA), followed by genotyping by reverse transcription PCR (RT-PCR). Norovirus genogroups were determined by TaqMan-based quantitative RT-PCR. Among 406 enrolled children, 75 (18.47%), 223 (54.93%) and 29 (7.14%) cases were positive for norovirus, rotavirus and both viruses (mixed infections), respectively. Most cases clinically presented with fever, diarrhea, vomiting and some degree of dehydration. The majority (n = 69/75 [92%]) of the noroviruses identified belonged to genogroup II, and several genotypes were identified by sequencing a subset of samples. Among 35 samples tested for rotavirus genotype, the most prevalent genotype was G3P[8] (n = 30/35 [85.6%]). Our study suggests that the burden of norovirus diseases in Indonesian children should not be underestimated. It also shows the emergence of rotavirus genotype G3P[8] in Indonesia.

True Pathogen or Contamination: Validation of Blood Cultures for the Diagnosis of Nosocomial Infections in a Developing Country

BACKGROUND

Blood culture results are frequently used to guide antibiotic decision-making, but culture contaminants need to be distinguished from true pathogens.

AIMS

To assess the contamination rate of blood cultures and validate a method to distinguish between true bacteraemia and contamination.

METHODS

We analysed blood culture results from children who were admitted to the paediatric ICU and paediatric wards at the Sardjito Hospital, Yogyakarta, Indonesia between December 2010 and February 2013. For each positive culture result, the type of isolated organism, time to positivity, and the number of positive culture sites were considered to classify the isolate as representing a true bacteraemia or contaminant.

RESULTS

There were 1293 cultures obtained from blood and 308 (23.8%) were positive for bacterial growth. Fifty-three (4.1%) of the total cultures drawn fulfilled criteria for contaminants. The most common blood culture contaminants were coagulase-negative staphylococci.

CONCLUSION

Using standardized criteria, it is possible to implement a working method to identify true nosocomial infection from blood culture contaminant, and thus limit the effect of contaminated blood culture on irrational antibiotic use.

Human Neonatal Rotavirus Vaccine (RV3-BB) to Target Rotavirus from Birth

BACKGROUND

A strategy of administering a neonatal rotavirus vaccine at birth to target early prevention of rotavirus gastroenteritis may address some of the barriers to global implementation of a rotavirus vaccine.

METHODS

We conducted a randomized, double-blind, placebo-controlled trial in Indonesia to evaluate the efficacy of an oral human neonatal rotavirus vaccine (RV3-BB) in preventing rotavirus gastroenteritis. Healthy newborns received three doses of RV3-BB, administered according to a neonatal schedule (0 to 5 days, 8 weeks, and 14 weeks of age) or an infant schedule (8 weeks, 14 weeks, and 18 weeks of age), or placebo. The primary analysis was conducted in the per-protocol population, which included only participants who received all four doses of vaccine or placebo within the visit windows, with secondary analyses performed in the intention-to-treat population, which included all participants who underwent randomization.

RESULTS

Among the 1513 participants in the per-protocol population, severe rotavirus gastroenteritis occurred up to the age of 18 months in 5.6% of the participants in the placebo group (28 of 504 babies), in 1.4% in the neonatal-schedule vaccine group (7 of 498), and in 2.7% in the infant-schedule vaccine group (14 of 511). This resulted in a vaccine efficacy of 75% (95% confidence interval [CI], 44 to 91) in the neonatal-schedule group (P<0.001), 51% (95% CI, 7 to 76) in the infant-schedule group (P=0.03), and 63% (95% CI, 34 to 80) in the neonatal-schedule and infant-schedule groups combined (combined vaccine group) (P<0.001). Similar results were observed in the intention-to-treat analysis (1649 participants); the vaccine efficacy was 68% (95% CI, 35 to 86) in the neonatal-schedule group (P=0.001), 52% (95% CI, 11 to 76) in the infant-schedule group (P=0.02), and 60% (95% CI, 31 to 76) in the combined vaccine group (P<0.001). Vaccine response, as evidenced by serum immune response or shedding of RV3-BB in the stool, occurred in 78 of 83 participants (94%) in the neonatal-schedule group and in 83 of 84 participants (99%) in the infant-schedule group. The incidence of adverse events was similar across the groups. No episodes of intussusception occurred within the 21-day risk period after administration of any dose of vaccine or placebo, and one episode of intussusception occurred 114 days after the third dose of vaccine in the infant-schedule group.

CONCLUSIONS

RV3-BB was efficacious in preventing severe rotavirus gastroenteritis when administered according to a neonatal or an infant schedule in Indonesia. (Funded by the Bill and Melinda Gates Foundation and others; Australian New Zealand Clinical Trials Registry number, ACTRN12612001282875 .).

Significance of continuous rotavirus and norovirus surveillance in Indonesia

BACKGROUND

Diarrhea significantly contributes to the global burden of diseases, particularly in developing countries. Rotavirus and norovirus are the most dominant viral agents responsible for diarrheal disease globally. The aim of this review was to conduct a comprehensive assessment of rotavirus and norovirus study in Indonesia.

DATA SOURCES

Articles about rotavirus and norovirus surveillance in Indonesia were collected from databases, including PubMed and Google Scholar. Manual searching was performed to identify additional studies. Furthermore, relevant articles about norovirus diseases were included.

RESULTS

A national surveillance of rotavirus-associated gastroenteritis has been conducted for years, resulting in substantial evidence about the high burden of the diseases in Indonesia. In contrast, norovirus infection received relatively lower attention and very limited data are available about the incidence and circulating genotypes. Norovirus causes sporadic and epidemic gastroenteritis globally. It is also emerging as a health problem in immunocompromised individuals. During post-rotavirus vaccination era, norovirus potentially emerges as the most frequent cause of diarrheal diseases.

CONCLUSIONS

Our review identifies knowledge gaps in Indonesia about the burden of norovirus diseases and the circulating genotypes. Therefore, there is a pressing need to conduct national surveillance to raise awareness of the community and national health authority about the actual burden of norovirus disease in Indonesia. Continuing rotavirus surveillance is also important to assess vaccine effectiveness and to continue tracking any substantial changes of circulating rotavirus genotypes.

Clinical profile of congenital rubella syndrome in Yogyakarta, Indonesia

BACKGROUND

Congenital rubella syndrome (CRS) has many severe neurological manifestations and other systemic consequences. Although various studies have been done in Indonesia, there are no conclusive results on CRS incidence. The aim of this study was therefore to investigate the incidence, clinical manifestations and outcomes of CRS in Yogyakarta, Indonesia.

METHODS

A descriptive study involving a review of congenital anomalies associated with CRS was carried out at Dr Sardjito Hospital, Yogyakarta, Indonesia, from July 2008 to June 2013. CRS was categorized according to the World Health Organization (WHO) classification. This study involved children aged <1 year old, and was conducted at the outpatient clinic, pediatric and neonatology wards.

RESULTS

A total of 201 children met the criteria for suspected CRS during the 5 year study. Of those patients, 6% were classified as having laboratory-confirmed CRS, 21.4% as having clinically compatible CRS, and 72.6% as having discarded CRS (i.e. a suspected case that does not meet the criteria for CRS). The estimated incidence of laboratory-confirmed CRS and laboratory-confirmed and clinically compatible CRS in Yogyakarta, Indonesia during the study period was 0.05:1,000 and 0.25:1,000 live births, respectively. Of the laboratory-confirmed CRS patients, 83.3% of children had congenital heart disease (CHD), 75% had hearing impairment, 66.7% had congenital cataract and 50% had microcephaly. Furthermore, none of the mothers was vaccinated against rubella.

CONCLUSIONS

The incidence of CRS in infants in Yogyakarta Indonesia is considered high, with most clinical manifestations being CHD, hearing impairment and congenital cataract. This emphasizes the necessity for epidemiological study of CRS in other hospitals and the importance of establishing a national rubella vaccination program in Indonesia.

Nutritional status, exclusive breastfeeding and management of acute respiratory illness and diarrhea in the first 6 months of life in infants from two regions of Indonesia

BACKGROUND

Infant morbidity and mortality rates remain high in Indonesia, with acute respiratory illnesses (ARI) and diarrhea the leading two health problems in children under 5 years. We aimed to describe the nutritional status, feeding practice and case management of ARI and diarrhea of infants from two regions of Indonesia during the first 6 months of life.

METHODS

This study was an observational study conducted in parallel to an immunogenicity and efficacy trial of an oral rotavirus vaccine (RV3-BB) in the Klaten and Yogyakarta regions, Indonesia. Mothers were interviewed at 3 time points: within the first 6 days of their infant's life, and at 8-10 and 22-24 weeks of age. Questions asked included pregnancy history, infant nutritional status, feeding status and health of infants within up to 2 weeks prior to the assessment.

RESULTS

Between February 2013 and January 2014, 233 mother-infant pairs were recruited. 60% (136/223) of infants were exclusively breastfed (EBF) until 6 months of age with the strongest support for EBF reported by mothers themselves 70% (101/223) and 25% (36/223) from their partners. At 6 months, 6% (14/223) of infants were underweight and severely underweight; 4% (8/ 223) wasted and severely wasted; and 12% (28/223) were stunted and severely stunted. Non-recommended medication use was high, with 54% (21/39) of infants with reported cough within 2 weeks of an assessment receiving cough medication, 70% (27 /39) an antihistamine, 26% (10/39) a mucolytic and 15% (6 /39) an oral bronchodilator. At age 22-24 week, infants with reported diarrhea within 2 weeks of an assessment had low use of oral rehydration solutions (ORS) (3/21;14%) and zinc therapy (2/ 21;10%).

CONCLUSION

In this unique observational study, breastfeeding rates of 60% at 6 months were below the Indonesian national target of >75%. Adherence to WHO guidelines for management of ARI and diarrhea was poor, with high use of non-recommended cough medications and oral bronchodilators in the first 6 months of life and low use of ORS and zinc therapy. Ongoing education of primary health care workers and parents regarding management of common illness is needed in Indonesia.

Unsupervised primaquine for the treatment of Plasmodium vivax malaria relapses in southern Papua: A hospital-based cohort study

BACKGROUND

Primaquine is the only licensed drug for eradicating Plasmodium vivax hypnozoites and, therefore, preventing relapses of vivax malaria. It is a vital component of global malaria elimination efforts. Primaquine is efficacious when supervised in clinical trials, but its effectiveness in real-world settings is unknown. We aimed to determine whether unsupervised primaquine was effective for preventing re-presentation to hospital with vivax malaria in southern Papua, Indonesia.

METHODS AND FINDINGS

Routinely-collected hospital surveillance data were used to undertake a pragmatic comparison of the risk of re-presentation to hospital with vivax malaria in patients prescribed dihydroartemisinin-piperaquine (DHP) combined with primaquine versus those patients prescribed DHP alone. The omission of primaquine was predominantly due to 3 stock outages. Individual clinical, pharmacy, and laboratory data were merged using individual hospital identification numbers and the date of presentation to hospital. Between April 2004 and December 2013, there were 86,797 documented episodes of vivax malaria, of which 62,492 (72.0%) were included in the analysis. The risk of re-presentation with vivax malaria within 1 year was 33.8% (95% confidence Interval [CI] 33.1%-34.5%) after initial monoinfection with P. vivax and 29.2% (95% CI 28.1%-30.4%) after mixed-species infection. The risk of re-presentation with P. vivax malaria was higher in children 1 to <5 years of age (49.6% [95% CI 48.4%-50.9%]) compared to patients 15 years of age or older (24.2% [95% CI 23.4-24.9%]); Adjusted Hazard Ratio (AHR) = 2.23 (95% CI 2.15-2.31), p < 0.001. Overall, the risk of re-presentation was 37.2% (95% CI 35.6%-38.8%) in patients who were prescribed no primaquine compared to 31.6% (95% CI 30.9%-32.3%) in those prescribed either a low (≥1.5 mg/kg and <5 mg/kg) or high (≥5 mg/kg) dose of primaquine (AHR = 0.90 [95% CI 0.86-0.95, p < 0.001]). Limiting the comparison to high dose versus no primaquine in the period during and 12 months before and after a large stock outage resulted in minimal change in the estimated clinical effectiveness of primaquine (AHR 0.91, 95% CI 0.85-0.97, p = 0.003). Our pragmatic study avoided the clinical influences associated with prospective study involvement but was subject to attrition bias caused by passive follow-up.

CONCLUSIONS

Unsupervised primaquine for vivax malaria, prescribed according to the current World Health Organization guidelines, was associated with a minimal reduction in the risk of clinical recurrence within 1 year in Papua, Indonesia. New strategies for the effective radical cure of vivax malaria are needed in resource-poor settings.

Hospital-based surveillance of congenital rubella syndrome in Indonesia

Congenital rubella syndrome (CRS) has serious consequences, such as miscarriage, stillbirth, and severe birth defects in infants, resulting from rubella virus infection during pregnancy. However, rubella vaccine has not yet been implemented in Indonesia. This study aimed (1) to estimate the incidence of CRS in Indonesia, (2) describe the clinical features of CRS at our referral hospital, and (3) pilot a CRS surveillance system to be extended to other hospitals. We conducted a 4-month prospective surveillance study of infants aged <1 year with suspected CRS in 2013 at an Indonesian hospital. Infants with suspected CRS were examined for rubella-specific IgM antibody or rubella IgG antibody levels. Of 47 suspected cases of CRS, 11/47 (23.4%), 9/47 (19.1%), and 27/47 (57.5%) were diagnosed as laboratory-confirmed, clinically compatible, and discarded CRS, respectively. The most common defects among laboratory-confirmed CRS cases were hearing impairment (100%), congenital cataracts (72.7%), microcephaly (72.7%), and congenital heart defects (45.5%).

CONCLUSION

The number of laboratory-confirmed CRS cases among Indonesian infants is high. Furthermore, hearing impairment is the most common clinical feature of CRS in infants. Our findings indicate the importance of implementation of rubella vaccine in Indonesia. Conducting hospital-based surveillance of CRS in other hospitals in Indonesia may be appropriate. What is Known: •Congenital rubella syndrome (CRS) has serious consequences in infants resulting from rubella virus infection during pregnancy. •The incidence of CRS in most developed countries has greatly decreased since implementation of rubella vaccination. •Rubella vaccine has not yet been implemented in many developing countries. What is New: •The number of laboratory-confirmed CRS cases among Indonesian infants was high. •Implementation of rubella vaccine into immunization programs in Indonesia is important because of the high number of CRS cases. •Our study highlights the need for ongoing prospective surveillance of CRS in Indonesia.

Penyebaran Spesialis Anak di Indonesia Tahun 2004: Implikasinya Terhadap Kebijakan Kesehatan dan Pendidikan

Komposisi penyebaran tenaga dokter spesialis anak (SpA) di tingkat propinsi di Indonesiamasih belum merata. Distribusi penyebaran tenaga spesialis ini hampir 70% berpusat diJawa dan Bali, bahkan tercatat di beberapa propinsi lain yang tidak memiliki satupuntenaga SpA. Tulisan ini menyajikan distribusi penyebaran SpA di setiap di propinsi diIndonesia dan proporsi pertumbuhan SpA berdasarkan jenis kelamin. Dalam tulisan inijuga didiskusikan beberapa implikasi terhadap kebijakan yang mungkin dapat dijadikanpertimbangan dalam pengembangan model distribusi tenaga SpA.

Diare Rotavirus pada Anak Usia Balita

Latar belakang. Rotavirus merupakan penyebab tersering diare akut berat pada anak balita. Peningkatan yang pesat di bidang teknologi diagnostik memungkinkan dilakukan identifikasi genotipe rotavirus penyebab diare. Belum banyak penelitian di Indonesia yang melaporkan hubungan antara genotipe rotavirus dengan manifestasi klinisnya. Tujuan. Mengetahui hubungan antara genotipe rotavirus dengan gambaran klinis.Metode. Penelitian potong lintang dengan subyek pasien diare akut yang berobat di Poliklinik Anak atau dirawat inap di RS DR Sardjito. Subyek yang bersedia berpartisipasi dalam penelitian diambil data klinis dan sampel tinja untuk dilakukan pemeriksaan rotavirus dengan enzyme immunoassaydan deteksi genotipe dengan pemeriksaan RT-PCR (Gentsch, 1992). Dilakukan penilaian derajat keparahan diare menggunakan 20-point severity scoring systemyang dimodifikasiHasil.Selama Januari 2006 - Maret 2007 didapatkan 353 kasus diare akut, 116 (32,68%) di antaranya positif terinfeksi rotavirus. Prevalensi tertinggi dijumpai pada kelompok usia 6-23 bulan (65,5%). Diare rotavirus menunjukkan gejala klinis yang lebih berat (severity score>11) dibanding diare karena penyebab lain (RR=1,27, IK 95% 1,08-1,49). Jenis genotipe rotavirus yang paling banyak ditemukan adalah G1 (27,5%) diikuti dengan G9 (18%), G2 (17%), G4 (3%), G3 (2%). Kombinasi G-P terbanyak adalah G1 P[6] (20%). Tipe untypeable(28.6%) dan G 1 (28.6%) paling sering memberikan gejala klinis berat (severity scoring >11) diikuti dengan G 9 (23.8%). Kesimpulan. Pasien diare rotavirus yang untypeable dan G 1 lebih sering mengalami dehidrasi dan muntah serta memberikan gambaran klinis yang lebih berat. Sangat penting mendeteksi lebih jauh jenis genotipe dari untypeableuntuk kepentingan pembuatan vaksin rotavirus yang mampu melindungi terhadap berbagai macam galur rotavirus.

The accuracy of clinical diagnosis for dehydration according to the integrated management of childhood illness

Background Acute diarrheal disease causes over 5 milion deathsworldwide in children under 5 years old, mostly because of failureto detect and treat dehydration properly and immediately.Objective To determine the validity of clinical diagnosis of dehy-dration according to Integrated Management of Childhood Illness(IMCI) as a diagnostic test for dehydration in children under fiveyears old.Methods A prospective observational study was done for clinicaldiagnosis in dehydration. Children aged 2 months-5 years old withdiarrhea and or vomiting who visited the primary health centers inYogyakarta were enrolled. Clinical diagnosis was made by atrained IMCI nurses. Dehydration was defined as the presence ofdecreasing consciousness, very sunken eyes, slow reaction whenoffered a drink, and decreased skin elasticity. Ninety-five per-cents confidence intervals (CI) were calculated, and the signifi-cance was assessed by X 2 .Results There were 148 children aged 2 months to 5 years oldenrolled this study. Clinical dehydration used according to IMCIproduced sensitivity of 91% (95% CI 83;98), specificity of 82%(95% CI 75;89), positive predictive value (PPV) of 70% (95% CI58;77), negative predictive value (NPV) of 94% (95% CI 90;98),positive likehood ratio of 5.17 (95% CI 3.37;7.94), and negativelikehood ratio of 0.11 (95% CI 0.04;0.27).Conclusion Clinical diagnosis for dehydration according to IMCIis sufficiently accurate as a diagnostic test for dehydration in chil-dren under 5 years old

Prognostic factors of refractory epilepsy in children

Background Epilepsy is one of the most common pediatricneurological disorders. Twenty percent of patients will developrefractory epilepsy. Early identification of refractory epilepsy willbe helpful to conduct adequate counseling and selecting patientswho need more intensive investigation and treatment.Objective To identify the clinical characteristics and other factorsthat are related to refractory epilepsy in children.Methods We conducted a case control study in patients of two to18 years old with epilepsy that admitted to Dr. Sardjito Hospital.There were 4 7 children with refractory epilepsy compared with122 subjects who have been one year free of seizure.Results Strong association had been noted between refractoryand several clinical factors: early onset of seizure, high initialseizure frequency, neonatal asphyxia, symptomatic etiology, statusepilepticus, abnormal neurodevelopmental status, and earlybreakthrough seizures after treatment initiation. On multivariateanalysis, more than 20 seizures prior to treatment initiation (OR3.40, 95% CI 1.03 to 11.3), and more than three seizures in thesubsequent six month after treatment initiation (OR 16.02, 95%CI 4.98 to 51.5) were independent prognostic factors related torefractory epilepsy.Conclusion Children who present high frequency seizures atonset and more than 3 breakthrough seizures subsequent to sixmonth after treatment have risks of developing refractory epilepsy.

McIsaac criteria for diagnosis of acute group-A β-hemolytic streptococcal pharyngitis

Background The early use of antibiotics for acute upper respiratory infections is controversial because most of these infections are caused by viruses. A strategy is needed to correctly identify the causitive agents of acute pharyngitis, so that antibiotics can be prescribed appropriately.Objective To assess McIsaac criteria for diagnosing acute group-A β-hemolytic streptococcal (GABHS) pharyngitis in children.Methods This diagnostic study was conducted from August 2011 to February 2012, to compare clinical criteria of McIsaac to throat swab culture results as the gold standard for diagnosis. Subjects were children aged 3-14 years who visited the pediatric outpatient clinic or emergency ward at Sanglah Hospital and the pediatric outpatient clinic at Wangaya Hospital.Results There were 550 cases of acute pharyngitis during the study period, with 313 patients aged 3-14 years and 199 patients excluded due to a history of taking antibiotics in the two weeks prior to the hospital visit. Hence, 114 subjects were eligible for the study. GABHS prevalence in this study was 7.9%. McIsaac’s area under the curve (AUC) from receiver operating characteristic (ROC) curve was 78.1%(95%CI 60.3 to 96%, P= 0.005). A McIsaac score ≥4 had a 66.7% (95%CI 49 to 97%) sensitivity, 87.6% (95% CI 81 to 94%) specificity, 31.6% (95 %CI 11 to 52%) positive predictive value (PPV), 96.8% (95%CI 93 to 100%) negative predictive value (NPV), 86.0% accuracy, 5.4 (95% CI 2.7 to 10.7) positive likelihood ratio (LR+) and 0.4 (95% CI 0.2 to 0.9) negative likelihood ratio (LR-).Conclusion A McIsaac criteria total score of <4 is favorable for excluding a diagnosis of GABHS pharyngitis. A McIsaac total criteria score of ≥4 requires further examination to confirm a diagnosis of GABHS pharyngitis.

ANTIBIOTIC RESISTANCE AND MORTALITY IN CHILDREN WITH NOSOCOMIAL BLOODSTREAM INFECTION IN A TEACHING HOSPITAL IN INDONESIA

Nosocomial infection is a major problem in hospitals worldwide. Understanding patterns of bacterial etiology and antibiotic susceptibility are important factors to combating nosocomial infection. Among children with nosocomial bloodstream infection (BSI), we identified pathogens and determined antibiotics resistance patterns and mortality rates for antibiotic-susceptible and multidrugresistant (MDR) infection in patients with nosocomial BSI in pediatric wards and PICU at Dr Sardjito Hospital, Indonesia during December 2010 to February 2013. Of 174 isolates from 170 patients, 168 pathogens were bacteria, of which 148 were gram-negative. Pseudomonas aeruginosa, Klebsiella spp, Enterobacteriaceae, Acinetobacter baumanii, and Escherichia coli was found in 55%, 6%, 4%, 1%, and <1%, respectively of the isolates. Imipenem, amikacin, ciprofloxacin, and ceftazadime had the highest sensitivity to nosocomial pathogens at 86%, 84%, 84%, and 75%, respectively. Eleven patients had MDR-infections, 7 of whom died. Among 153 patients infected with bacteria resistant to <3 classes of antibiotics (non-MDR), mortality was 40%, and among 4 patients with fully drug-susceptible sepsis only one died. Thus, substantial mortality was observed in children with nosocomial-BSI, particularly with MDR pathogens. Given the further high risk of resistance with wider use of carbapenems, third generation cephalosporins and flouroquinolones, prevention should be given highest priority in combating hospital-acquired infection.

Asymptomatic Vivax and Falciparum Parasitaemia with Helminth Co-Infection: Major Risk Factors for Anaemia in Early Life

BACKGROUND

Anaemia in children under five years old is associated with poor health, growth and developmental outcomes. In Papua, Indonesia, where the burden of anaemia in infants is high, we conducted a community survey to assess the association between Plasmodium infection, helminth carriage and the risk of anaemia.

METHODS

A cross sectional household survey was carried out between April and July 2013 in 16 villages in the District of Mimika using a multistage sampling procedure. A total of 629 children aged 1-59 months from 800 households were included in the study. Demographic, symptom and anthropometry data were recorded using a standardized questionnaire. Blood and stool samples were collected for examination.

RESULTS

Of the 533 children with blood film examination, 8.8% (47) had P. vivax parasitaemia and 3.9% (21) had P. falciparum; the majority of children with malaria were asymptomatic (94.4%, 68/72). Soil transmitted helminth (STH) infection was present in 43% (105/269) of children assessed; those with STH were at significantly greater risk of P. vivax parasitaemia compared to those without STH (OR = 3.7 [95%CI 1.5-9.2], p = 0.004). Anaemia (Hb<10 g/dl) was present in 24.5% (122/497) of children and associated with P. vivax parasitaemia (OR = 2.9 [95%CI, 1.7-4.9], p = 0.001), P. falciparum parasitaemia (OR = 4.3 [95%CI, 2.0-9.4], p<0.001), hookworm carriage (OR = 2.6 [95%CI, 1.2-5.8], p = 0.026), Plasmodium-helminth coinfection (OR 4.0 [95%CI, 1.4-11.3], p = 0.008) and severe stunting (OR = 1.9 ([95%CI, 1.1-3.3], p = 0.012).

CONCLUSIONS

Asymptomatic P. vivax and P. falciparum infections and hookworm all contribute to risk of paediatric anaemia in coendemic areas and should be targeted with prevention and treatment programs. The relationship between helminth infections and the increased risk of P. vivax parasitaemia should be explored prospectively.

Prevalence and clinical characteristics of rotavirus diarrhea in Mataram, Lombok, Indonesia

diarrhea and dehydration among children aged <5 years in developed and developing countries, including Indonesia. There have been few studies on the prevalence of rotavirus diarrhea in Mataram.Objective To determine the prevalence and characteristics of rotavirus diarrhea in children under five years of age with acute diarrhea in Mataram.Methods A cross sectional study using the WHO Generic Protocol for Rotavirus Surveillance was conducted in the Nusa Tenggara Barat (NTB) General Hospital, Mataram, as part of a multicenter study by the Indonesian Rotavirus Surveillance Network (IRSN) for children under five years of age. Subjects were diagnosed with rotavirus diarrhea based on stool sample examinations, using RT-PCR for genotyping. They were admitted to the Pediatrics Ward of the NTB Provincial General Hospital from January to December 2010.Results Of 329 children admitted with acute diarrhea, 210 (63.8%) had rotavirus positive stool specimens. For the year 2010, the highest incidence of rotavirus infection was in the month of January (86.4%). Rotavirus infections were found in children less than 2 years of age (65.4%), with the highest prevalence in the age group of 6 to 23 months (68.5%). In addition to clinical symptoms of watery diarrhea, there was a significantly greater percentage of vomiting in rotaviral vs. non-rotaviral diarrhea (67.7% vs. 32.3%, respectively; P<0.05). The majority of G and P genotypes found were G1 (86%), G2 (12%), P[8] (66%), P[4] (12.8%), and P[6] (8%).Conclusion Rotavirus infections are the most common cause of acute diarrhea in children aged <2 years in Mataram, Indonesia.

Detection of group A rotavirus strains circulating among children with acute diarrhea in Indonesia

Rotavirus is the major cause of severe diarrhea in children under 5 years old in developed and developing countries. Since improvements in sanitation and hygiene have limited impact on reducing the incidence of rotavirus diarrhea, implementation of a vaccine will be a better solution. We conducted an observational study to determine the disease burden and to identify the genotype of circulating rotavirus in Indonesia. Hospitalized children due to acute diarrhea were enrolled from four teaching hospitals in Indonesia. Stool samples were collected based on WHO protocol and were tested for the presence of group A rotavirus using enzyme immunoassay. Then, rotavirus positive samples were genotyped using RT-PCR. Fisher’s Exact tests, Chi square tests and logistic regression were performed to determine differences across hospital and year in rotavirus prevalence and genotype distribution. There were 4235 samples from hospitalized children with diarrhea during 2006, 2009 and 2010. Among them, the rotavirus positive were 2220 samples (52.42 %) and incidence rates varied between hospitals. The G1P[8], G1P[6], and G2P[4] were recognized as the dominant genotypes circulating strains in Indonesia and the proportion of predominant strains changed by year. Our study showed the high incidence of rotavirus infection in Indonesia with G1P[8], G1P[6], and G2P[4] as the dominant strains circulating in Indonesia. These results reinforce the need for a continuing surveillance of rotavirus strain in Indonesia.

Knowledge and attitudes towards rotavirus diarrhea and the vaccine amongst healthcare providers in Yogyakarta Indonesia

Background

Rotavirus has been identified as the most common pathogen associated with severe diarrhoea. Two effective vaccines against the pathogen have been licensed. However, many countries including Indonesia have yet to introduce the vaccine into their national immunisation programs. This study aimed to examine the attitudes of healthcare providers (HCPs) and other health stakeholders towards the pathogen and the vaccine.

Methods

Semi-structured in-depth interviews were undertaken in two districts of Yogyakarta Province, Indonesia with nurses, midwives, primary care providers, pediatricians and other health stakeholders. Thematic analysis was undertaken.

Results

Fourteen interviews were conducted between August and October 2013. We identified that while participants do not consider diarrhea to be an important problem in Indonesia, they do acknowledge that it can be serious if not properly treated. While the majority had some level of knowledge about rotavirus, not all participants knew that a vaccine was available. There were mixed feelings towards the need for the vaccine. Some felt that the vaccine is not ranked as a priority as it is not listed on the national program. However, others agreed there is a rationale for its use in Indonesia. The cost of the vaccine (when sold in the private sector) was perceived to be the primary barrier impacting on its use.

Conclusions

The high cost and the low priority given to this vaccine by the public health authorities are the biggest obstacles impacting on the acceptance of this vaccine in Indonesia. HCPs need to be reminded of the burden of disease associated with rotavirus. In addition, reminding providers about the costs associated with treating severe cases versus the costs associated with prevention may assist with improving the acceptance of HCPs towards the vaccine. Promotion campaigns need to target the range of HCPs involved in the provision of care to infants and pregnant women.

RET and EDNRB mutation screening in patients with Hirschsprung disease: Functional studies and its implications for genetic counseling

Hirschsprung disease (HSCR) is a major cause of chronic constipation in children. HSCR can be caused by germline mutations in RET and EDNRB. Defining causality of the mutations identified is difficult and almost exclusively based on in silico predictions. Therefore, the reported frequency of pathogenic mutations might be overestimated. We combined mutation analysis with functional assays to determine the frequencies of proven pathogenic RET and EDNRB mutations in HSCR. We sequenced RET and EDNRB in 57 HSCR patients. The identified RET-coding variants were introduced into RET constructs and these were transfected into HEK293 cells to determine RET phosphorylation and activation via ERK. An exon trap experiment was performed to check a possible splice-site mutation. We identified eight rare RET-coding variants, one possible splice-site variant, but no rare EDNRB variants. Western blotting showed that three coding variants p.(Pr270Leu), p.(Ala756Val) and p.(Tyr1062Cys) resulted in lower activation of RET. Moreover, only two RET variants (p.(Ala756Val) and p.(Tyr1062Cys)) resulted in reduced ERK activation. Splice-site assays on c.1880-11A>G could not confirm its pathogenicity. Our data suggest that indeed almost half of the identified rare variants are proven pathogenic and that, hence, functional studies are essential for proper genetic counseling.

Risk of nutritional status on diarrhea among under five children

Background Diarrhea is still the leading cause of children’s mortality worldwide and the main cause of malnutrition. Meanwhile, malnourished children are proven to have more severe, prolonged, and frequent episodes of diarrhea, making them a vicious circle.Objective To investigate the risk of nutritional status on diarrheal severity and duration as well as length of hospital stay.Methods We conducted a cross sectional study involving 176 under five children who admitted to Mataram Province Hospital with acute diarrhea since January until December 2013. We analyzed data using logistic regression model.Results Most subjects were infants (median 12 months, range 1-53), male (56.8%), well-nourished (85.8%), admitted with acute watery diarrhea (97.2%), mild-to-moderate dehydration (71.6%), diarrhea severity score ≥11 (74.4%), duration of diarrhea ≤7 days (96.6%), and length of stay <5 days (73.3%). Logistic regression model indicated significant risk of nutritional status on length of hospital stay (adjusted OR 2.09, 95% CI 1.06 to 6.38), but neither diarrheal severity (adjusted OR 1.03, 95% CI 0.38 to 2.80) nor duration of diarrhea (adjusted OR = 1.17, 95% CI = 0.13 to 10.89) indicated significant risks. However, malnourished children had more severe (76% versus 74.2%) and longer duration (4% versus 3.3%) of diarrhea than well-nourished children.Conclusion Nutritional status is the risk for length of hospital stay in under-five children admitted with acute diarrhea. [

Reducing hospital-acquired infections and improving the rational use of antibiotics in a developing country: an effectiveness study

BACKGROUND

Prevention of hospital-acquired infections (HAI) is central to providing safe and high quality healthcare. Transmission of infection between patients by health workers, and the irrational use of antibiotics have been identified as preventable aetiological factors for HAIs. Few studies have addressed this in developing countries.

AIMS

To implement a multifaceted infection control and antibiotic stewardship programme and evaluate its effectiveness on HAIs and antibiotic use.

METHODS

A before-and-after study was conducted over 27 months in a teaching hospital in Indonesia. All children admitted to the paediatric intensive care unit and paediatric wards were observed daily. Assessment of HAIs was made based on the criteria from the Centers for Disease Control and Prevention. The multifaceted intervention consisted of a hand hygiene campaign, antibiotic stewardship (using the WHO Pocket Book of Hospital Care for Children guidelines as standards of antibiotic prescribing for community-acquired infections), and other elementary infection control practices. Data were collected using an identical method in the preintervention and postintervention periods.

RESULTS

We observed a major reduction in HAIs, from 22.6% (277/1227 patients) in the preintervention period to 8.6% (123/1419 patients) in the postintervention period (relative risk (RR) (95% CI) 0.38 (0.31 to 0.46)). Inappropriate antibiotic use declined from 43% (336 of 780 patients who were prescribed antibiotics) to 20.6% (182 of 882 patients) (RR 0.46 (0.40 to 0.55)). Hand hygiene compliance increased from 18.9% (319/1690) to 62.9% (1125/1789) (RR 3.33 (2.99 to 3.70)). In-hospital mortality decreased from 10.4% (127/1227) to 8% (114/1419) (RR 0.78 (0.61 to 0.97)).

CONCLUSIONS

Multifaceted infection control interventions are effective in reducing HAI rates, improving the rational use of antibiotics, increasing hand hygiene compliance, and may reduce mortality in hospitalised children in developing countries.

Efficacy of synbiotic treatment in children with acute rotavirus diarrhea

Background Diarrhea is one of the major causes of morbidityand mortality in children throughout the world, mostly due torotavirus infection. In daily practice, we routinely use the WorldHealth Organization Five steps for managing acute diarrhea.Thispractice has shown great success in diarrhea management, butconcerns remain on reducing the duration of diarrhea to preventcomplications. Synbiotics can reduce the severity of diarrhea.However, there has been limited data on synbiotic therapy fortreating acute rotavirus diarrhea in children.Objective To compare the durations of acute rotavirus diarrheatreated with synbiotics vs. placebo.Methods This study was a randomized, double-blind, clinical trial,performed at the Pediatric Gastrohepatology Division, Sanglahand Wangaya Hospitals in Denpasar. Subjects were children aged6 to 59 months with acute rotavirus diarrhea. Rotavirus wasdiagnosed by immune chromatography assay. The synbiotic groupreceived probiotic comprised of Lactobacillus sp., Streptococcus sp.,Bifidobacterium sp. (total viable count 1.00x109 CFU per dose), andprebiotic consisted of 990.00 mg fructooligosacharide (FOS). Theplacebo consisted of lactose monohydrate packaged similarly as thesynbiotics. Subjects orally ingested 1 pack per day for 5 days.Results Seventy children with acute rotavirus diarrhea wasinvolved in this study. The median duration of diarrhea in thesynbiotic group was 50.0 (SE 1.1); 95%CI 47.9 to 52.1 hours, whilethat of the placebo group was 63.0 (SE 5.9); 95%CI 51.4 to 74.6hours. Based on Kaplan-Meier survival analysis, the duration ofdiarrhea in the synbiotic group was significantly shorter than thatof the placebo group (log-rank test P <0.0001).Conclusion In children with acute rotaviral diarrhea, synbioticreduces the duration of diarrhea compared to placebo.

Risk factors of rotavirus diarrhea in hospitalized children in Sanglah Hospital, Denpasar: a prospective cohort study

Background

Diarrhea is a major public health concern throughout the world because the prevalence of morbidity of diarrhea has not changed significantly in the past decade. It remains the third leading cause of death among children less than 5 years of age. Recent surveillance studies have shown that rotavirus is a significant cause of pediatric hospitalization and death due to diarrhea. Indonesia has limited data on risk factors, disease burden, and deaths in children due to rotavirus diarrhea. The objective of this study was to examine the above mentioned factors related to rotavirus diarrhea in hospitalized children in Sanglah Hospital, Denpasar.

Methods

A prospective cohort study was conducted at Sanglah Hospital Denpasar from April 2009 to December 2011. The present study was part of a nationwide study on Extension for Hospital-based Surveillance and Strain Characterization of Rotavirus Diarrhea Indonesia involving four hospitals throughout Indonesia as a part of the Asian Rotavirus Surveillance Network. We studied children aged <5 years who were hospitalized with acute diarrhea, and analyzed their stool samples using an immunoassay that detects the rotavirus antigen.

Results

A total of 656 patients met the inclusion criteria for this study. Of 5805 patients under the age of 5 who were hospitalized between April 2009 and December 2011, the prevalence of diarrhea among hospitalized pediatric patients was 11.3% and the prevalence of rotavirus diarrhea was 49.8%. The male to female ratio of those affected by rotavirus was 1.6:1. The occurrence of vomiting was significantly higher in rotavirus diarrhea than in non-rotavirus diarrhea (RR, 1.4; 95% CI, 1.08 to 1.70; p = 0.004).

Conclusions

Diarrhea remains an important cause of hospitalization in children, and rotavirus was the most important etiology. We found that boys had a greatest risk of rotavirus infection than girls. Good nutritional status and breastfeeding provided the same protection against rotavirus and non-rotavirus diarrhea.

Prevention of nosocomial infections in developing countries, a systematic review

BACKGROUND

Prevention of nosocomial infection is key to providing good quality, safe healthcare. Infection control programmes (hand-hygiene campaigns and antibiotic stewardship) are effective in reducing nosocomial infections in developed countries. However, the effectiveness of these programmes in developing countries is uncertain.

OBJECTIVE

To evaluate the effectiveness of interventions for preventing nosocomial infections in developing countries.

METHODS

A systematic search for studies which evaluated interventions to prevent nosocomial infection in both adults and children in developing countries was undertaken using PubMed. Only intervention trials with a randomized controlled, quasi-experimental or sequential design were included. Where there was adequate homogeneity, a meta-analysis of specific interventions was performed using the Mantel-Haenzel fixed effects method to estimate the pooled risk difference.

RESULTS

Thirty-four studies were found. Most studies were from South America and Asia. Most were before-and-after intervention studies from tertiary urban hospitals. Hand-hygiene campaigns that were a major component of multifaceted interventions (18 studies) showed the strongest effectiveness for reducing nosocomial infection rates (median effect 49%, effect range 12.7-100%). Hand-hygiene campaigns alone and studies of antibiotic stewardship to improve rational antibiotic use reduced nosocomial infection rates in three studies [risk difference (RD) of -0.09 (95%CI -0.12 to -0.07) and RD of -0.02 (95% CI -0.02 to -0.01), respectively].

CONCLUSIONS

Multifaceted interventions including hand-hygiene campaigns, antibiotic stewardship and other elementary infection control practices are effective in developing countries. The modest effect size of hand-hygiene campaigns alone and negligible effect size of antibiotic stewardship reflect the limited number of studies with sufficient homogeneity to conduct meta-analyses.

Effects of Phyllanthus niruri on the severity of the common cold in children

Background Common cold is a self􀀵limited disease, howeverit poses a significant burden on productivity and communityhealth. Unfortunately, there has been no standard medicationfor childhood common cold, whereas some herbs \\lith immune􀀵modulating properties, such as Phyllanthus niruri extract (PNE),might be beneficial but has not been thoroughly studied.Objective To evaluate the effect of PNE administration on theseverity of common cold symptoms in children.Methods We performed a randomized, double􀀵blind, controlledtrial in children aged 2􀀵6 years who were diagnosed Mth a commoncold at primary health care centers in Sewon and Jetis in Bantul,as well as in Gondomanan and Gedongtengen in Yogyakarta.Subjects were collected by consecutive sampling and parentswere interviewed. We assessed illness severity by Hemila scoringfor the common cold.Results A total of 100 subjects were included Mth 50 subjects ineach intervention group. After treatment, there was no significantdifference in common cold severity between the PNE and thecontrol groups for all symptom score components, including cough(0.87 vs 0.71, P􀀽0.36), nasal symptom (0.90 vs 1.10, P􀀽0.54),coryza ( 0.44 vs 1.10, P=0.54), and systemic symptom (0.10 vs0.10, P􀀽0.94).Conclusion Administration of PNE for 6 days did not provide asignificant benefit in reducing the severity of the common coldcompared to placebo in children aged 2 - 6 years. [PaediatrIndanes.2012;52:346-51].

Surveillance of rotavirus diarrhea

Background Rotavirus is a major cause of severe diarrhea anddehydration in children worldwide. Data on the burden of diseasein Indonesia is limited.Objective To provide an epidemiological profile of rotavirusinfection among children hospitalized for diarrhea in MohammadHoesin Hospital, Palembang.Methods In January- December 2006, a prospective, hospitalbasedsurveillance was carried out in children aged less thanfive years, presenting with diarrhea. Stool samples wereexamined for rotavirus using enzyme immunoassay (EIA).G- and P-typing were performed on specimens confirmed tobe positive by EIA.Results A total of 513 fecal specimens from 534 children weretested for rotavirus. Rotavirus was detected in 64% of thespecimens, mostly of the G9 type (62.5%). Incidence ofrotavirusdiarrhea was highest in the 6 month to 2 years age group (60.4%).Children with rotavirus diarrhea were more likely to present withdehydration, compared to those with non-rotavirus diarrhea (94%vs 70%, respectively, P=0.03).Conclusion Rotavirus was the most common pathogen foundin children with diarrhea. Rotavirus was detected in 64% ofpediatric diarrheal specimens tested in our study. This findingwarrants the use of a large-scale program to prevent disease,such as vaccination against rotavirus. [Paediatr lndones.2012;52:22-7].

Evaluation of stool microbiota signatures in two cohorts of Asian (Singapore and Indonesia) newborns at risk of atopy

Background

Studies have suggested that demographic and lifestyle factors could shape the composition of fecal microbiota in early life. This study evaluated infant stool microbiota signatures in two Asian populations, Singapore (n = 42) and Indonesia (n = 32) with contrasting socioeconomic development, and examined the putative influences of demographic factors on these human fecal associated bacterial signatures.

Results

Longitudinal analysis showed associations of geographical origin with Clostridium leptum, Atopobium and Bifidobacterium groups. Mode of delivery had the largest effect on stool microbiota signatures influencing the abundance of four bacterial groups. Significantly higher abundance of bacterial members belonging to the Bacteroides-Prevotella, Bifidobacterium and Atopobium groups, but lower abundance of Lactobacilli-Enterococci group members, were observed in vaginal delivered compared to caesarean delivered infants. Demographic factors influencing the structure of infants stool microbiota during the first year of life included breastfeeding, age of weaning, sibship size and exposure to antibiotics.

Conclusions

Differences in stool microbiota signatures were observed in relation to various demographic factors. These features may confound studies relating to the association of the structure of fecal microbiota and the predisposition to human modern disease.

Epidemiology of Rotavirus diarrhea in children under five: A hospital-based surveillance in Jakarta

Background Rotavirus is still a major cause of acute diarrhea in children around the world, both in developed and developingcountries. WHO Surveillance from 2001 to 2008 showed that in children under five years of age treated for acute diarrhea, on average 40% of cases were caused by rotavirus. A previous study in Indonesia showed that the incidence of rotavirus diarrhea in children ranged from 20%􀁑60% of diarrhea cases. However, there have been few studies identifying the genotypes of rotavirus strains in Indonesia. This infonnation is indispensable for manufacturing vaccines.Objective To examine the epidemiology of rotavirus diarrhea, including genotypes and clinical characteristics, in children under five years who were hospitalized in Jakarta.Methods This study was a prospective surveillance conducted at Cipto Mangunkusumo Hospital, Jakarta from January to December 2007 investigating hospitalized children under five years of age who suffered from acute diarrhea.Results Ninety􀁑nine patients joined the study. The incidence of rotavirus infection in this study was 67%. The youngest was 2months of age and the oldest 54 months of age, Mth an average age of 13.6 months. As much as 92% of rota virus diarrhea was found in subjects aged 3􀁑23 months, Mth a peak age of 12􀁑23 months. Nutritional status, degree of dehydration, bloating, fever, blood in stool, and mucus in the feces were not significantly different between rotavirus and non􀁑rotavirus diarrhea. Vomiting tended to be more frequently experienced by children Mth rotavirus diarrhea than those with non􀁑rotavirus (88% vs. 67%). There was no clear, seasonal pattern for rotavirus diarrhea. Most G genotypes in this study were G1 (35%), G9 (12.5%), G2 (7.5%) and the majority of P genotypes were P6 (52.5%), P8 (17.5%) and P4 (10%).Conclusions The incidence of rotavirus diarrhea in hospitalized children under five years of age in Jakarta was 67%, with apredominance ofG1, G9 and G2 genotypes. 

Maternal antibodies to rotavirus: could they interfere with live rotavirus vaccines in developing countries?

INTRODUCTION

Past experience with live oral vaccines including licensed rotavirus vaccines demonstrates a trend towards reduced vaccine efficacy in developing countries compared with developed countries. The reasons behind this disparity are not well understood. Transplacental transfer of maternal antibodies and breast milk ingestion may attenuate vaccine responses in infants in developing countries where rotavirus infections are endemic, and maternal antibody levels are high. We examined the prevalence and level of rotavirus antibody in maternal and cord serum, colostrum and breast milk in a developing country setting.

METHODS

100 mother-infant pairs were prospectively recruited from December 2008 to February 2009 at Dr. Sardjito Hospital, Yogyakarta, Indonesia. Maternal and cord sera were collected during delivery. Colostrum and transitional breast milk were collected between day 0-3 and day 7-10 postpartum respectively. Rotavirus-specific IgA and IgG were estimated for all specimens and virus neutralization assays were conducted on a subset of milk specimens.

RESULTS

All maternal and cord serum samples were positive for rotavirus-specific IgG antibodies with a strong correlation between levels of rotavirus-specific IgG in mothers and levels transferred to infants in cord blood (r=0.86; p=0.001). 78% of colostrum and 67% of transitional breast milk specimens were positive for rotavirus-specific IgA. There was a median 4-fold decrease in rotavirus-specific IgA from colostrum to transitional breast milk. Neutralizing antibodies were present in 56% of colostrum specimens assayed (19/34) and in 41% of transitional milk specimens assayed (14/34).

CONCLUSIONS

Maternal serum and breast milk antibodies to rotavirus are highly prevalent in a developing country setting. Evaluation of the impact of maternal anti-rotavirus serum and breast milk antibody upon vaccine immunogenicity would help to inform rotavirus vaccination strategies, especially in developing settings.