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ROTAVIRUS- CHALLENGES AHEAD
- Dr. Gulrukh Hashmi
OVERVIEW
Introduction
Disease burden
Virus description
Epidemiology
Vaccine
Challenges
Conclusion
INTRODUCTION
Diarrhea remains one of the commonest illnesses of
childhood.
In developing countries it is 3rd most common cause of
deaths
20 different pathogens cause diarrhea.
Rotavirus causes 25-55% hospital admissions for
diarrhea
DISEASE BURDEN
Rotavirus is the most common cause of severe diarrhea
in infants and young children worldwide.
Globally it is responsible for 611,000 childhood deaths
More than 80% deaths occur in low-income countries
and India records the highest mortality
ROTAVIRUS DISEASE BURDEN IN INDIA
122,000-153,000
457,000-884,000
2 million
Estimated annual number and risk of death, hospitalization, and outpatientvisits due to rotavirus diarrhea in children <5 years of age in India.
Adapted from: J. E. Tate et al. Disease and economic burden of rotavirus diarrhea in India/Vaccine 27 S (2009) F18–F24
EVENTSRISK
1 in every 177-196 children
1 in every 31-59 children
1 in every 13 children
Deaths
Hospitalizations
Outpatient Visits
FINANCIAL BURDEN
It is estimated that India spends approximately Rs 1.8–3.2 billion
(US$ 37.4 to 66.8 million) in direct medical costs annually
Rs 107–176 million (US$ 2.2–3.7 million) in non-medical costs
for the treatment of rotavirus diarrhea in children <5 years of age
With a total burden of Rs 2.0–3.4 billion (US$ 41–72 million)
VIROLOGY
Rotaviruses are double stranded RNA viruses
Belongs to the family Reoviridae
Scientists have described 7 groups(A-G)
Only A,B,C infect humans
of which A is commonest.
A is further divided in G and
P serotypes
MODE OF TRANSMISSION
Faeco-oral route
Direct contact
Fomites
Respiratory droplets
Incubation period - 24 to 48 hrs
CLINICAL MANIFESTATIONS
Vomiting
Mild watery diarrhea of short duration
Severe gastroenteritis
Life-threatening dehydration secondary to
gastrointestinal fluid loss
Majority of children become infected with rotavirus
within the first three years of life
With a peak incidence of rotavirus diarrhea between six
to 24 months of age
Initial infection after 3months of age is most likely to
cause severe diarrhea and dehydration.
PREVENTIVE MEASURES
Breast-feeding
Hand washing
Improve water quality and sanitation
Oral rehydration therapy- to prevent
dehydration
IMPROVEMENT IN HYGIENE AND SANITATION DOES NOT SIGNIFICANTLY REDUCE ROTAVIRUS INFECTION
Almost every child infected by 2 year irrespective of socio economic class
Rotavirus is highly contagious
Resistant to inactivation
Highly Stable
ROTAVIRUS DIARRHEA AND ORT
Oral rehydration therapy reduces mortality but does not
decrease the episode duration or their consequences such
as malnutrition.
Adherence to ORT is poor.
Leads to use of antibiotics or other treatment of no
proven value.
Resistance to disinfectants
Ineffectiveness to ORS
Need for effective vaccine
VACCINES
RotaShield
Rotarix
RotaTeq
Rotavac
Two oral, live, attenuated rotavirus vaccines
Rotarix (GlaxoSmithKline Biologicals,Rixensart,
Belgium)
RotaTeq (Merck & Co. Inc., West Point, PA, USA)
Available internationally
Both vaccines are considered safe and effective
WHO now recommends that infants worldwide be
vaccinated against Rotavirus
Rotavirus Vaccines
RotaTeq RotarixManufacturer Merk & Co. GSK
Genetic framework
Bovine Rotavirus – WC3
Human Rotavirus-89-12
Composition 5 Human, Bovine reassortant
Single Human rotavirus
Genotypes G1, 2, 3, 4 and [P8] G1 [P8]
Dosage Schedule 3 doses at 2, 4 and 6 months
2 doses at 2 and 4 months
Route oral oral
Presentation liquid Lysophilized-reconstituted
Efficacy against severe disease
85% 95%
Virus shedding Up to 13 % 17 % - 27%
ROTARIX™ VACCINE
Administered orally
A two-dose schedule
Infants approximately 2 and 4 months of age
The first dose can be administered at the age of 6 weeks and must
be given no later than the age of 12 weeks.
The interval between the two doses should be at least 4 weeks.
The two-dose schedule should be completed by age 16 weeks and
not later than 24 weeks of age
ROTATEQ™ VACCINE
Three oral doses at ages 2, 4, and 6months.
The first dose should be administered between ages 6 – 12
weeks and subsequent doses at intervals of 4 – 10 weeks.
Vaccination should not be initiated for infants aged > 12
weeks.
All three doses should be administered before the age of 32
weeks
BENEFITS OF VACCINATION
A universal rotavirus immunization program in
Asia has the potential to avert
109,000 deaths
1.4 million hospitalizations
7.7 million outpatient visits, and US $ 139
million in healthcare costs each year, for
children < 5 years of age,
ROTAVAC
Developed by Govt of India
and Bharat biotech
Oral vaccine to be given in 3 doses at 6,10 and 14
weeks.
More affordable than the other two vaccines
Needs to be licensed and sanctioned by WHO before it
can be sold in India and distributed globally
ROTAVAC
The efficacy of vaccine in study was 50 to 58% while
that of Rotarix vaccine in West is 90%.
The trials for vaccine enrolled only 6,779 infants.
Impossible to compare the side effects of this vaccine
with the previously available ones
CHALLENGES FOR IMPLEMENTATION
Monitoring impact of rotavirus vaccines on diarrheal
disease burden in resource-limited settings
Improving rotavirus vaccine performance in developing
countries.
Monitoring the safety of rotavirus vaccines & further
understanding the relationship between rotavirus
vaccines and intussusceptions
CHALLENGES
Monitoring rotavirus vaccine impact on circulating
rotavirus strains
Overcoming programmatic challenges
Accurate information on vaccine risk and benefits to
maintain public trust in rotavirus immunization
Ensuring adequate vaccine supply and competition
CONCLUSION
Rotavirus diarrhea is a significant public health problem
in India
Rotavirus accounts for more severe dehydrating diarrhea
in children.
In view of continuing high morbidity and mortality from
rotavirus diarrhea and enormous economic consequences
thereof, there is a strong case for immunization against
rotavirus infection in India.
CONCLUSION
Availability of current rotavirus vaccines and continued
development of new rotavirus vaccines
Introduction of the vaccine in routine immunisation
schedule
Progress needed in different areas.
Decline in morbidity and mortality
REFERENCES
WHO AFMC’s Textbook of Public health and community medicine
Shaun K Morris, Shally Awasthi,Ajay Khera,Diego G Basani. Rotavirus mortality in India: estimates based on a nationally representative survey of diarrheal deaths ; Bull Word Health Organisation 2012,90:720-727.
Penelope H Dennehy. Rotavirus Vaccine : an overview Clinical Microbiology Reviews,Jan 2008,198-208 Vol 21,No.1
J.E.Tate,Manish m Patel, Global impact of rotavirus vaccines expert review Vaccines 9 (4), 395-40407(2010)
REFERENCES
Dheeraj shah, panna choudhary, piyush Gupta Promoting appropriate management of diarrhea: a systematic review of literature for advocacy and action: Unicef-PhFI series on newborn and child health,India Indian Pediatrics Journal Vol 49-August 16,2012627-650.
Rakesh Lodha and Dheeraj Shah. Prevention of Rotavirus Diarrhea in India: Is Vaccination the Only Strategy?. Indian Pediatr 2012;49: 441-443
Paramita Sengupta. Rotavirus: The Challenges Ahead . Glass RI, Parashar VD, Bresee JS, Turcios R, Fischer TK,
Widowson MA, et al. Rotavirus vaccines: current prospects and future challenges. Lancet.2006;368:323–32.
REFERENCES
Naik TN. Commentary. Rapid diagnosis of rotavirus infection: prevent unnecessary use of antibiotics for treatment of children Diarrhea. Indian J Med Res.2004;119:5–7
WHO. World Health Org Report of the meeting on future directions for rotavirus vaccine research in developing countries. Geneva: 2000. Feb, Report no. WHO/VandB/00.23.
Pratibha Masand. Propaganda by consumer goods companies to curb rotavirus infection.
Consensus recommendation on immunization and IAP Immunization time table 2012. Indian academy of Paediatrics Committee on Immunization. Indian paediatrics, July 2012;vol. 49.pp 549-564.