Prevention of rotavirus in india is vaccination the only strategy.


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Prevention of rotavirus in india is vaccination the only strategy.

  1. 1. Guided by – Dr. Y.D. Badgaiyan Prof. and Head Deptt of Community Medicine CIMS, Bilaspur (C.G.)
  2. 2.  Diarrhea, is the third leading killer of children in India.  It is responsible for 13% of all deaths in children <5 years of age.  It kills an estimated 3,00,000 children in India each year.
  3. 3.  Rotaviruses are the major agents causing endemic and epidemic of diarrhea in young children in both developed and developing countries.  In India, approximately 30% of hospitalized diarrhea cases are caused by rotaviruses.
  4. 4.  In India, 1 of every 250 children die of rotavirus diarrhea each year.  Which is about 17 percent of the world’s estimated rotavirus deaths.
  5. 5.  No specific treatment available but, vaccines are available for prevention of Rotavirus diarrhea.  WHO’s Strategic Advisory Group of Experts (SAGE) on immunization has recommended inclusion of rotavirus vaccine in the National Schedules in countries, where < 5 mortality due to diarrheal diseases is ≥ 10%.
  6. 6.  Before inclusion of rotavirus vaccine in National Immunization Programme in India, we have to consider a few laid down criteria for an informed decision making.  Disease burden, safety and efficacy, affordability, programme capacity and cost- effectiveness of the vaccination programme are important issues.
  7. 7.  Rotaviruses have a distinct wheel like appearance in electron microscopy,  thus have been named rota which in latin means wheel.  Virus is member of the family Reoviridae, and it has a genome of 11 segments of double- stranded RNA.
  8. 8.  The rotaviruses are divided in seven groups A,B,C (human and animal viruses) and D,E,F,G (animal viruses).  Group A rotaviruses are the most frequently identified pathogens.
  9. 9.  Rotavirus diarrhea is most common in children of 6-24 months age group.  Rotavirus infections display seasonal pattern with peak incidence in winter (Oct-Feb).  Risk factors are overcrowding and malnutrition.
  10. 10.  Rota viruses are transmitted by the feco-oral route through contaminated environment.  Respiratory route of transmission through aerosol is also suggested.
  11. 11.  Low grade fever,  vomiting,  watery diarrhea,  dehydration, and irritability.  Tachycardia and shock, resulting in ischemic injury to the kidneys and CNS are rare complications.
  12. 12.  The incubation period of rotavirus diarrhoea varies from 1-7 days.  In newborns, the infection is usually asymptomatic, but 8-24 per cent of neonates may have minimal diarrhoea, and vomiting associated with fever.
  13. 13.  In infants and young children, there is an abrupt onset of severe vomiting and diarrhea.  Vomiting usually precedes the onset of diarrhoea.  Stools are usually loose and watery, mucus may be present in 25 per cent of cases but blood is very rare.
  14. 14.  Mild to moderate dehydration is seen in 80 per cent of cases and severe loss of fluids and electrolytes may be fatal if untreated.  Mild fever is seen in a large majority of cases.
  15. 15.  The illness usually lasts 3-8 days, but virus shedding continues for about 10 days to 1 month.  In immunodeficient children, rotavirus can persist for months.
  16. 16.  Older children and adults are infected but they generally suffer from subclinical infections and virus is infrequently detected in their stool samples.
  17. 17.  Rotavirus is excreted in large numbers in the faeces (>106 particles/g faeces).  Direct EM examination of stool sample for rotavirus is specific test and has a sensitivity of 80-90 per cent.
  18. 18.  Other common tests are - - LA (Latex Agglutination) - ELISA and - PAGE (Poly- Acrylamide Gel Electrophoresis).  Most widely used method is ELISA.
  19. 19.  Reverse Transcriptase – polymerase chain reaction (RT-PCR) is confirmatory methods for detecting rotavirus in stool samples.
  20. 20.  Rotavirus is currently by far the most common cause of severe diarrhea in infants and young children worldwide and of diarrheal deaths in developing countries.  Rotavirus shows proportionately increasing trend with time.
  21. 21.  It is estimated that rotavirus accounted for 21% hospitalized cases with diarrhea from 1986 to 1999,  which increased to 39% of hospitalized cases with diarrhea in the period 2000–2004.
  22. 22.  Rotavirus diarrhea causes about 6,11,000 childhood deaths (454,000–705,000).  More than 80% of these deaths occur in low- income countries.
  23. 23.  Based on WHO estimates, in India there is 3.2 episodes of diarrhea per child per year (2008).  and  110 million episodes of diarrhea in children under 5 year of age.
  24. 24.  Studies between 2001 and 2009 in India also showed an increasing trend of rotavirus isolation from 23.5% to 39.2% among hospitalized children with diarrhea.
  25. 25.  It is postulated that improvements in sanitation and use of antimicrobials have had a greater impact on prevention of bacterial and parasitic gastroenteritis (GE) , but not for the rotavirus diarrhea.
  26. 26.  The prevalence of rotavirus in neonates is high in India, ranging from 22% to 73% .  Neonatal infections are commonly asymptomatic, with 69-95% not showing overt signs of GE.
  27. 27.  Most rotavirus disease in India occurs in the first two years of life.  In hospital-based studies, 87% (ISV: 58- 95%) of all rotavirus cases in children under 5 yr occurred by 18 months of age.
  28. 28.  Additionally, rotavirus Gastro-enteritis is uncommon in the youngest children.  Only 13% (ISV: 10-25%) of rotavirus cases in hospital studies were in children younger than 6 months old.
  29. 29.  In young children, infection with rotavirus may be attenuated by the persistence of maternal antibodies and thus, severe disease is less common.
  30. 30.  Most studies in India have found association between rotavirus infection and time of year.  Most have observed an increase in rotavirus- associated diarrhea during the winter months, October to February, throughout the country.
  31. 31.  The observed proportion of rotavirus cases occurring in the cooler season has ranged from 59% to 72%.  The northern, more temperate regions may exhibit stronger seasonality.
  32. 32.  Rotavirus isolates from India are genetically heterogeneous.  Such genetic diversity is characteristic of Asia as a whole.  It is suggested that rotavirus strains circulating in India are part of a larger Asian transmission pool.
  33. 33.  No specific treatment exists for rotavirus gastroenteritis, and repeated infections are common in children.  Sanitation and hygiene improvements have had a tremendous impact on diarrheal diseases due to bacteria and parasites but less impact on rotavirus disease.
  34. 34.  Reduced osmolality oral rehydration solution (ORS) effectively prevents and treats dehydration, and also reduces diarrheal output.  But the 2005 National Family Health Survey found that only 26% of children with diarrhea receive ORS.
  35. 35.  Unlike many other diarrheal pathogens, the proportion of diarrhea caused by rotavirus does not vary widely between developed and developing countries.  To date, the only specific prevention strategy is immunization with rotavirus vaccines.
  36. 36.  Currently, two rotavirus vaccines are available on the international market.  1. Rotarix  2. Rota Teq
  37. 37.  Rotarix (GlaxoSmithKline, Rixensart, Belgium) is a mono-valent rotavirus vaccine.  (RV1) created by attenuating a highly antigenic strain of human G1P rotavirus.
  38. 38.  Rota Teq (Merck and Co., Whitehouse Station, USA) is a penta-valent vaccine.  (RV5) created by re-assorting G and P antigens from human rotavirus, G1, G2, G3, G4 and P with a bovine rotavirus strain.
  39. 39.  These vaccines appear to be cross protective against non-vaccine strains, with similar efficacy against vaccine and non-vaccine strains.  In high and middle income countries, recent introductions of RV1 and RV5 have had remarkable impact on rotavirus disease despite limited uptake in the under 5 population.
  40. 40.  Based on the experiences of other developing countries, a rotavirus vaccine introduced in India would be expected to exhibit lower efficacy against rotavirus GE than seen in high income countries,  but still prevent a significant proportion of all-cause GE mortality and hospitalizations.
  41. 41.  Live oral vaccines have had an inconsistent performance in India and other developing countries.  For example, oral polio vaccine (OPV) is less immunogenic and requires more doses to protect children in India compared with children in the developed world.
  42. 42.  In developing countries, higher levels of maternal rotavirus antibodies are passively transferred to babies during gestation and persist in infancy.  Other reasons for poor vaccine performance could be a higher prevalence of distinct medical conditions such as tuberculosis, intestinal infections and malnutrition.
  43. 43.  It is estimated that at current immunization levels, a national rotavirus vaccination program in India would prevent 27,000 to 44,000 deaths in children <5 years of age annually.  Rotavirus vaccine would prevent 1 case of severe gastroenteritis disease for every 11 children immunized, and prevent one death for every 470 children immunized.
  44. 44.  The potential impact of rotavirus vaccines in India is partially hindered by a relatively low proportion of children who receive routine immunizations.  If full immunization with rotavirus vaccine were reached, an additional 14,000 rotavirus deaths each year could be prevented.
  45. 45.  Improving the overall performance of the immunization system is critical to the success of any vaccine introduction.
  46. 46.  Rotavirus diarrhea causes substantial mortality and morbidity in young children in India with the greatest burden among children <2 years of age.  Despite the tremendous diversity of rotavirus strains in India, rotavirus vaccines provide cross-protection and have been shown to be effective against both vaccine and non- vaccine strains.
  47. 47.  At current coverage levels of routine childhood immunizations, the introduction of rotavirus vaccine in India could prevent up to only one third of rotavirus-related deaths.  Introduction of rotavirus vaccine into the national immunization program of India at an affordable price would be a cost effective way to reduce the tremendous morbidity and mortality due to rotavirus disease in Indian children.
  48. 48. THANK YOU