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Nicaragua:Early Experience with Routine Use
of Rotavirus VaccinesDr. Juan Jose Amador – PATH Nicaragua
8th International Rotavirus Symposium, Istanbul, Turkey
3-4 June 2008
Nicaragua
11141051 1034
1301 1301
1439
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1634
849
612 622
492536
443 461 449
245204 191
145 17498 122 90
0
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Acute Diarrhoeal Disease Mortality in Children < 1 Year of AgeNicaragua, 1983-2006
Source: SINEVI (National Statistic System for Mortality)
CholeraeIntroduction ToLatin America
Last Case of Cholerae
Timeline of Events Related to the Rotavirus Vaccination
2006 2007
LaunchOct. 27th
2006
NationalPediatricsConferenceAug. 19th
AMNCongress Aug. 31st
ClintonGlobal
Initiative Sept. 22nd
NationalTraining
UAM Auditorium
Strengthening of the Epidemiological Surveillance
VaccinationStartsEntire
Country
2nd DoseApplied
3rd DoseApplied
Merck and MoH
HEODRASurveillance
Surveillance and
EffectivenessStudy
MoH-PAHO PATH-CDCMay 14th
HurricaneFelix
Beginning ofNegotiations
with manufacturers
DecisionMade:
RotaTeq
NCIP
First TAGMeeting July 24th
AllianceMoH, PATH
NGO New MoHAuthorities
2005
2005 Epidemics
CDCPAHOMoH
Research
PATHVisit to
PromoteRotavirusVaccine
NEJMPublications NCIP
Effectiveness 5 aditional hospitals
TAGTelecom meeting
Merck visitPAHO/CDC visit
The Ministry of Health of NicaraguaDecided to Introduce the RotaTeq VaccinesTo the National Scheme of Immunization
On May 2006
August 17th 2006 – UAM Workshop
LAUNCHOCTOBER 27TH 2006
LAUNCHOCTOBER 27TH 2006
National Campaign April to May 2007 Routine Immunizations 2007
New Government strong support
• 5 November 2006 elections resulted in President Daniel Ortega government
• 10 January 2007, new Minister of Health Dra. Maritza Cuan takes office
• 02 November 2007, New Minister of Health Dr. Guillermo González
• High promotion of Community Participation in Health
Rotavirus Vaccination in NicaraguaOctober 2006 – April 2008
Coverage of the First, Second and Third Doses of Rotavirus Vaccine Children Under 1 Year of Age, Nicaragua, 2007 to 03/2008
*
%
* Not included data of April 2008
Coverage of the First, Second and Third Doses of Rotavirus Vaccine According to SILAIS of the First Cohort of Children Under 1 Year of Age
Nicaragua 2007
0
20
40
60
80
100
120
Carazo
Boaco
Madriz
N. Sego
via
Masay
aEste
lí
Granad
a
Chinan
dega
León
R.S.Juan
Rivas
Managu
a
Mataga
lpa
Jinote
ga
Chonta
lesRAAS
RAAN
Porc
enta
je R1
R2
R3%
Incidence of Intussusception for children < 1 Year of AgeNicaragua 2000-2007
Rate for 10 000 Rotavirus Vaccination
Start (Nov. 06)
AGE -- number of consultations at Primary Health Care Services, Nicaragua 1993-2007
Deaths Caused by AGE in Children <1 and 1 to 4 Years of Age, Nicaragua 2000-2007
Rotavirus Vaccination
Start (Nov.06)
Mortality Rate by Acute Diarrheal Diseases in Children Under 5, Nicaragua 2000-2005 and 2007
Rate x 100,000
Source: SINEVI (National Statistic System for Mortality)
Surveillance and Effectiveness Evaluation
• Merck, MINSA, UNAN-Leon: 6 sentinel hospitals• National Children Hospital Manuel de Jesus Rivera - La Mascota • The German-Nicaraguan Hospital in Managua, • Hospital Oscar Danilo Rosales Arguello (HEODRA) in León, • Maternity and Infant Hospital in Chinandega, • Hospital San Juan de Dios in Estelí• Hospital Friendship Japan-Nicaragua in Granada.
• PAHO/CDC/PATH/MoH: 4 sentinel hospitals• Hospital Fernando Vélez Paiz in Managua, • Santiago Regional Hospital in Jinotepe, • Hospital Humberto Alvarado in Masaya • Regional Hospital in Matagalpa.
Lessons Learned
• Strong collaboration
– Merck & Co., Inc.– PATH, PAHO, CDC,
UNICEF
– MoH, National NGOs
• Important issues:
– Planning and training
– Vaccine effectiveness
– Cold chain evaluation
– Media communication and Health Education
– Community Participation
• The vaccine has been well accepted by the medical and scientific community in the country, showing a good safety profile and minimum secondary effects.
• Health personnel were trained in the application of the vaccine in workshops implemented at different levels such as national, provinces, municipal, and local training sessions.
• Cold chain capacity adequate, but it was necessary to increase the frequency of vaccine deliveries (roughly double).
• Health professionals found vaccine convenient because it is orally-administered and does not require reconstitution.
• Occasionally, personnel did not follow technical norms by failing to introduce the applicator of the oral vaccine into the child’s mouth/cheek.
Summary
• AGE is a leading cause of <5 morbidity and mortality in Nicaragua
• Rotavirus was the cause of a large diarrheal outbreak in early 2005
• National, regional (PAHO) and international (WHO) policy supported the adoption of rotavirus vaccine
• Merck’s RotaTeq was introduced on 27 October 2006
• RotaTeq coverage is high, and improving as Rota1-Rota2-Rota3 drop out declines
• Surveillance is underway to document the impact of rotavirus vaccination and vaccine effectiveness (2009)
• Political commitment and broad collaboration is important for a successful vaccine introduction
THANKS