05 February 2010

Routine Adminstration of Rotavirus Vaccine in Developing Countries??

Rotavirus is the single leading cause of severe, potentially fatal diarrhea in the world today. 600,000 children, mainly infants in developing countries, die each year from Rotavirus infections. In comparison with enterotoxigenic E. coli, the second most common cause of fatal diarrhea in infants, rotavirus is more likely to cause fever, vomiting and abdominal pain, and antibiotics are totally ineffective in the treatment of this viral infection. Partial immunity is produced by initial infection, making subsequent exposure less likely to cause severe diarrhea. Severe clinical disease is also less likely in the first three months of life, probably due to residual maternal antibodies. Specific diagnosis can be made by rapid antigen detection, but is of limited value in clinical settings. Treatment is entirely supportive, mainly fluid replacement.
An effective vaccine has been available for over a decade. The initial preparation was associated with an unacceptably high rate of intussusception in infants, and was withdrawn. Two replacement vaccines are available which do not cause this problem. The vaccine is given orally at 2, 4, and 6 months of age. Extensive experience in developed countries has shown a total protection rate of 74% after 3 doses of vaccine, and a 98% reduction in cases of severe diarrhea. Thus far the vaccine has not been used extensively in developing countries for three reasons

1. The cost is prohibitive, basically unaffordable for routine use.
2. The vaccine requires refrigeration----that is an unbroken cold chain

3. The excellent protection noted above requires 3 doses at set intervals, a difficult task given the realities of immunization scheduling in developing countries.

Two recent large-scale Rotavirus vaccine studies in developing countries have been reported, one in Africa, the other in Mexico.(1). Both show excellent protection against severe rotavirus diarrhea, and demonstrate the feasibility of using the vaccine on a larger scale. Co-financing would make the vaccine much more affordable, and has been offered by the Global Alliance for Vaccines and Immunization, (GAVI), at least on a temporary basis. According to Shantosam (1), rotavirus vaccine should be introduced immediately in areas with high mortality from rotavirus infection. Combined with other proven interventions, routine immunization with rotavirus vaccine can substantially reduce the 1.8 million deaths from diarrhea that now devastate the developing world.

1. Santosham, M. Rotavirus Vaccine—A Powerful Tool to Combat Deaths from Diarrhea. NEJM 2010; 362:358-360.

Submitted by Roger Boe MD

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