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Prevention of rotavirus in india is vaccination the only strategy.
1. Guided by â
Dr. Y.D. Badgaiyan
Prof. and Head
Deptt of Community Medicine
CIMS, Bilaspur (C.G.)
2. ď˝ Diarrhea, is the third leading killer of children
in India.
ď˝ It is responsible for 13% of all deaths in
children <5 years of age.
ď˝ It kills an estimated 3,00,000 children in
India each year.
3. ď˝ Rotaviruses are the major agents causing
endemic and epidemic of diarrhea in young
children in both developed and developing
countries.
ď˝ In India, approximately 30% of hospitalized
diarrhea cases are caused by rotaviruses.
4. ď˝ In India, 1 of every 250 children die of
rotavirus diarrhea each year.
ď˝ Which is about 17 percent of the worldâs
estimated rotavirus deaths.
5. ď˝ No specific treatment available but,
vaccines are available for prevention
of Rotavirus diarrhea.
ď˝ WHOâs 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 ⼠10%.
6. ď˝ 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.
ď˝ Disease burden, safety and
efficacy, affordability, programme capacity
and cost- effectiveness of the vaccination
programme are important issues.
7.
8. ď˝ Rotaviruses have a distinct wheel like
appearance in electron microscopy,
ď˝ thus have been named rota which in latin
means wheel.
ď˝ Virus is member of the family Reoviridae, and
it has a genome of 11 segments of double-
stranded RNA.
9. ď˝ The rotaviruses are divided in seven groups
A,B,C (human and animal viruses) and D,E,F,G
(animal viruses).
ď˝ Group A rotaviruses are the most frequently
identified pathogens.
10.
11.
12. ď˝ Rotavirus diarrhea is most common in
children of 6-24 months age group.
ď˝ Rotavirus infections display seasonal pattern
with peak incidence in winter (Oct-Feb).
ď˝ Risk factors are overcrowding and
malnutrition.
13. ď˝ Rota viruses are transmitted by the feco-oral
route through contaminated environment.
ď˝ Respiratory route of transmission through
aerosol is also suggested.
14. ď˝ Low grade fever,
ď˝ vomiting,
ď˝ watery diarrhea,
ď˝ dehydration, and irritability.
ď˝ Tachycardia and shock, resulting in ischemic
injury to the kidneys and CNS are rare
complications.
15. ď˝ The incubation period of rotavirus diarrhoea
varies from 1-7 days.
ď˝ In newborns, the infection is usually
asymptomatic, but 8-24 per cent of neonates
may have minimal diarrhoea, and vomiting
associated with fever.
16. ď˝ In infants and young children, there is an
abrupt onset of severe vomiting and diarrhea.
ď˝ Vomiting usually precedes the onset of
diarrhoea.
ď˝ Stools are usually loose and watery, mucus
may be present in 25 per cent of cases but
blood is very rare.
17. ď˝ Mild to moderate dehydration is seen in 80
per cent of cases and severe loss of fluids
and electrolytes may be fatal if untreated.
ď˝ Mild fever is seen in a large majority of cases.
18. ď˝ The illness usually lasts 3-8 days, but virus
shedding continues for about 10 days to 1
month.
ď˝ In immunodeficient children, rotavirus can
persist for months.
19. ď˝ Older children and adults are infected but
they generally suffer from subclinical
infections and virus is infrequently detected
in their stool samples.
20. ď˝ Rotavirus is excreted in large numbers in the
faeces (>106 particles/g faeces).
ď˝ Direct EM examination of stool sample for
rotavirus is specific test and has a sensitivity
of 80-90 per cent.
21. ď˝ Other common tests are -
- LA (Latex Agglutination)
- ELISA and
- PAGE (Poly- Acrylamide Gel Electrophoresis).
ď Most widely used method is ELISA.
22. ď Reverse Transcriptase â polymerase chain
reaction (RT-PCR) is confirmatory methods
for detecting rotavirus in stool samples.
23.
24. ď˝ 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.
ď˝ Rotavirus shows proportionately increasing
trend with time.
25. ď˝ It is estimated that rotavirus accounted for
21% hospitalized cases with diarrhea from
1986 to 1999,
ď˝ which increased to 39% of hospitalized cases
with diarrhea in the period 2000â2004.
26. ď Rotavirus diarrhea causes about 6,11,000
childhood deaths (454,000â705,000).
ď˝ More than 80% of these deaths occur in low-
income countries.
27. ď˝ Based on WHO estimates, in India there is 3.2
episodes of diarrhea per child per year
(2008).
ď˝ and
ď˝ 110 million episodes of diarrhea in children
under 5 year of age.
28. ď˝ 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.
29. ď˝ 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.
30. ď˝ The prevalence of rotavirus in neonates is
high in India, ranging from 22% to 73% .
ď˝ Neonatal infections are commonly
asymptomatic, with 69-95% not showing
overt signs of GE.
31. ď˝ Most rotavirus disease in India occurs in the
first two years of life.
ď˝ In hospital-based studies, 87% (ISV: 58- 95%)
of all rotavirus cases in children under 5 yr
occurred by 18 months of age.
32. ď˝ Additionally, rotavirus Gastro-enteritis is
uncommon in the youngest children.
ď˝ Only 13% (ISV: 10-25%) of rotavirus cases in
hospital studies were in children younger
than 6 months old.
33. ď˝ In young children, infection with rotavirus
may be attenuated by the persistence of
maternal antibodies and thus, severe disease
is less common.
34. ď˝ Most studies in India have found association
between rotavirus infection and time of year.
ď˝ Most have observed an increase in rotavirus-
associated diarrhea during the winter
months, October to February, throughout the
country.
35. ď˝ The observed proportion of rotavirus cases
occurring in the cooler season has ranged
from 59% to 72%.
ď˝ The northern, more temperate regions may
exhibit stronger seasonality.
36. ď˝ Rotavirus isolates from India are genetically
heterogeneous.
ď˝ Such genetic diversity is characteristic of Asia
as a whole.
ď˝ It is suggested that rotavirus strains
circulating in India are part of a larger Asian
transmission pool.
37. ď˝ No specific treatment exists for rotavirus
gastroenteritis, and repeated infections are
common in children.
ď˝ Sanitation and hygiene improvements have
had a tremendous impact on diarrheal
diseases due to bacteria and parasites but
less impact on rotavirus disease.
38. ď˝ Reduced osmolality oral rehydration solution
(ORS) effectively prevents and treats
dehydration, and also reduces diarrheal
output.
ď˝ But the 2005 National Family Health Survey
found that only 26% of children with diarrhea
receive ORS.
39. ď˝ Unlike many other diarrheal pathogens, the
proportion of diarrhea caused by rotavirus
does not vary widely between developed and
developing countries.
ď˝ To date, the only specific prevention strategy
is immunization with rotavirus vaccines.
40.
41. ď˝ Currently, two rotavirus vaccines are available
on the international market.
ď˝ 1. Rotarix
ď˝ 2. Rota Teq
42. ď˝ Rotarix (GlaxoSmithKline, Rixensart, Belgium)
is a mono-valent rotavirus vaccine.
ď˝ (RV1) created by attenuating a highly
antigenic strain of human G1P rotavirus.
43. ď˝ Rota Teq (Merck and Co., Whitehouse
Station, USA) is a penta-valent vaccine.
ď˝ (RV5) created by re-assorting G and P
antigens from human
rotavirus, G1, G2, G3, G4 and P with a bovine
rotavirus strain.
44. ď˝ These vaccines appear to be cross protective
against non-vaccine strains, with similar
efficacy against vaccine and non-vaccine
strains.
ď˝ 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.
45. ď˝ 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,
ď˝ but still prevent a significant proportion of
all-cause GE mortality and hospitalizations.
46. ď˝ Live oral vaccines have had an inconsistent
performance in India and other developing
countries.
ď˝ 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.
47. ď˝ In developing countries, higher levels of
maternal rotavirus antibodies are passively
transferred to babies during gestation and
persist in infancy.
ď˝ Other reasons for poor vaccine performance
could be a higher prevalence of distinct
medical conditions such as
tuberculosis, intestinal infections and
malnutrition.
48. ď˝ 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.
ď˝ Rotavirus vaccine would prevent 1 case of
severe gastroenteritis disease for every 11
children immunized, and prevent one death
for every 470 children immunized.
49. ď˝ The potential impact of rotavirus vaccines in
India is partially hindered by a relatively low
proportion of children who receive routine
immunizations.
ď˝ If full immunization with rotavirus vaccine
were reached, an additional 14,000 rotavirus
deaths each year could be prevented.
50. ď˝ Improving the overall performance of the
immunization system is critical to the success
of any vaccine introduction.
51.
52. ď˝ Rotavirus diarrhea causes substantial
mortality and morbidity in young children in
India with the greatest burden among
children <2 years of age.
ď˝ 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.
53. ď˝ 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.
ď˝ 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.