Prevention of rotavirus in india is vaccination the only strategy.
Published on: Mar 4, 2016
Transcripts - Prevention of rotavirus in india is vaccination the only strategy.
Guided by –
Dr. Y.D. Badgaiyan
Prof. and Head
Deptt of Community Medicine
CIMS, Bilaspur (C.G.)
Diarrhea, is the third leading killer of children
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.
Rotaviruses are the major agents causing
endemic and epidemic of diarrhea in young
children in both developed and developing
In India, approximately 30% of hospitalized
diarrhea cases are caused by rotaviruses.
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.
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%.
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.
Rotaviruses have a distinct wheel like
appearance in electron microscopy,
thus have been named rota which in latin
Virus is member of the family Reoviridae, and
it has a genome of 11 segments of double-
The rotaviruses are divided in seven groups
A,B,C (human and animal viruses) and D,E,F,G
Group A rotaviruses are the most frequently
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
Rota viruses are transmitted by the feco-oral
route through contaminated environment.
Respiratory route of transmission through
aerosol is also suggested.
Low grade fever,
dehydration, and irritability.
Tachycardia and shock, resulting in ischemic
injury to the kidneys and CNS are rare
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.
In infants and young children, there is an
abrupt onset of severe vomiting and diarrhea.
Vomiting usually precedes the onset of
Stools are usually loose and watery, mucus
may be present in 25 per cent of cases but
blood is very rare.
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.
The illness usually lasts 3-8 days, but virus
shedding continues for about 10 days to 1
In immunodeficient children, rotavirus can
persist for months.
Older children and adults are infected but
they generally suffer from subclinical
infections and virus is infrequently detected
in their stool samples.
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.
Other common tests are -
- LA (Latex Agglutination)
- ELISA and
- PAGE (Poly- Acrylamide Gel Electrophoresis).
Most widely used method is ELISA.
Reverse Transcriptase – polymerase chain
reaction (RT-PCR) is confirmatory methods
for detecting rotavirus in stool samples.
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.
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.
Rotavirus diarrhea causes about 6,11,000
childhood deaths (454,000–705,000).
More than 80% of these deaths occur in low-
Based on WHO estimates, in India there is 3.2
episodes of diarrhea per child per year
110 million episodes of diarrhea in children
under 5 year of age.
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.
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.
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.
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.
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.
In young children, infection with rotavirus
may be attenuated by the persistence of
maternal antibodies and thus, severe disease
is less common.
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
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.
Rotavirus isolates from India are genetically
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
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.
Reduced osmolality oral rehydration solution
(ORS) effectively prevents and treats
dehydration, and also reduces diarrheal
But the 2005 National Family Health Survey
found that only 26% of children with diarrhea
Unlike many other diarrheal pathogens, the
proportion of diarrhea caused by rotavirus
does not vary widely between developed and
To date, the only specific prevention strategy
is immunization with rotavirus vaccines.
Currently, two rotavirus vaccines are available
on the international market.
2. Rota Teq
Rotarix (GlaxoSmithKline, Rixensart, Belgium)
is a mono-valent rotavirus vaccine.
(RV1) created by attenuating a highly
antigenic strain of human G1P rotavirus.
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
These vaccines appear to be cross protective
against non-vaccine strains, with similar
efficacy against vaccine and non-vaccine
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
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.
Live oral vaccines have had an inconsistent
performance in India and other developing
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.
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
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
Rotavirus vaccine would prevent 1 case of
severe gastroenteritis disease for every 11
children immunized, and prevent one death
for every 470 children immunized.
The potential impact of rotavirus vaccines in
India is partially hindered by a relatively low
proportion of children who receive routine
If full immunization with rotavirus vaccine
were reached, an additional 14,000 rotavirus
deaths each year could be prevented.
Improving the overall performance of the
immunization system is critical to the success
of any vaccine introduction.
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-
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