Samir K Saha, Ph.D Child Health Research Foundation Dhaka Shishu Hospital Dhaka, Bangladesh

Transcription

1 Barriers Rotavirus to Rotavirus Vaccine Impact Vaccine Beyond Preventing Introduction Diarrhea Samir K Saha, Ph.D Child Health Research Foundation Dhaka Shishu Hospital Dhaka, Bangladesh 13 th International Rotavirus Symposium, 2018 Minsk, Belarus August 1

2 BANGLADESH Achieved MDGs ahead of time 2

3 Bangladesh a pro-vaccine country with remarkable success in EPI programme Introduced Hib vaccine in 2009 Pneumococcal vaccine in

4 Leading infectious causes of mortality, 2000 estimates < 5 years old > 5 years old Deaths (millions) Pneumonia AIDS Diarrhoea TB Malaria Measles Source: WHO 4

5 1. The world is changing specifically the developing world Vaccine Preventable Diseases 5

6 Our Days in the Laboratory in 1980s Diphtheria cases everyday Tetanus was not uncommon Pneumococcus and Hib disease were enormous though only few laboratories could detect them 6

7 Country-specific mortality rates and deaths attributable to Pneumococcus and Hib in 2015 Pneumococcus Two vaccines have saved 1.45 million children s lives in the last 15 years Hib Wahl et al Lancet Glob Hlth

8 2. The world is changing specifically the developing world Vaccine uptake vs graduation of low income countries 8

9 Delayed Uptake of Available Preventives Million doses % coverage** 50% coverage** ESTIMATE HepB 75 lowest income countries % coverage** % coverage** Years from availability Hib - 75 lowest income countries 9

10 Growth of the Low Income /Emerging Countries 10

11 PCV Coverage, by Income Group 70% 60% 50% PCV Coverage (%) 40% 30% PCV-7 PCV-10/13 20% 10% 0% High income Upper-middle income Lower-middle income Low income Source: International Vaccine Access Center (IVAC), Johns Hopkins Bloomberg School of Public Health. Vaccine Information Management System (VIMS), data as of Sep Coverage based on WUENIC data, upd. as of Aug

12 3. The world is changing specifically the developing world MDG (MDG 4) /year 12.7 million 5.9 million SDG Aiming to achieve Good Health and Wellbeing SDG 3 Levels and Trends in Child Mortality, WHO

13 Barriers to Rotavirus Vaccine Introduction 14

14 Global Rotavirus Mortality Over Time Remarkable decrease in mortality Specifically South Asia Bangladesh Troegel et al JAMA Pediatr

15 Bangladesh - Most of the causes of <5 deaths are declining remarkably diarrhoea Under-5 Deaths per 1,000 live births Bangladesh Demographic and Health Surveys, 2004 &

16 Proportion of <5 death due to Pneumonia and Diarrhea in Bangladesh 25 % of death Diarrhoea Pneumonia Year Source: Liu et al. Population Health Metrics 2011, BDHS

17 Hesitancy among the policy makers Why? Minimal or no deaths from Rotavirus cases Patients are leaving hospital within hrs Has the concern about the continuation of PCV beyond Gavi eligibility 18

18 We explored the burden of Rotavirus and possible impact on Health System 19

19 Admission at Dhaka Shishu Hospital (N=23,064) the largest pediatric hospital (2017) Percentage %; 3,021 20

20 Rotavirus surveillance at Dhaka Shishu Hospital, Bangladesh during July-December, % (159/297) were rotavirus-positive among the enrolled cases. <3 months of age: 58% (19/33). <1 year: 51% (105/204) <2 years: 53% (137/258) Arif Tanmoy Frequency (number) Rota-positive 66 Rota-Negative 72 Cum. Rota(+)ve Cum. Rota(-)ve Age <3m 3-11m 12-23m 24-59m Rotavirus among acute watery diarrhea Cumulative percentage Tanmoy et al 2016 (PLoS One) 21

21 Rotavirus surveillance at Dhaka Shishu Hospital, Bangladesh during July-December, Prevalent genotypes: G12P[8] (35%; 55/159). G1P[8] (29%; 46/159) Frequency Gagandeep Kang Genotypes Circulating genotypes among rotavirus positive cases. Tanmoy AM et al 2016 (PLoS22One)

22 Admission at Dhaka Shishu Hospital (N=23,064) the largest pediatric hospital (2017) In 2017 to 23,000 admission, 15% of them are pneumonia Rotavirus diarrhea (13%) also a predominant cause of hospitalization However, 97% of cases are discharged within 48 hours. Based on such data, vaccines against pneumonia and meningitis have rightly been prioritized. Percentage %; 3,021 23

23 Fierce competition for beds in public hospitals At Resource poor setting, only 3 beds per 10,000 population, in comparison to 31 in the US Impact of Rota on the health systempossible impact of vaccine This leading to refusal of cases, just by putting a stamp BED NOT AVAILABLE huge burden on Health System In 2017 to 6000 admissible cases were refused A huge burden on the Health System Refused cases are more severe and vulnerable to deaths and disabilities Care seeking issues Pneumonia Severe perinatal asphyxia Acute gastroenteritis 7 Pre-term low birth weight 6 6 Neonatal sepsis Bronchiolitis Febrile convulsion Sepsis Neonatal jaundice Enteric fever Meningitis Nephrotic syndrome Dysentery Congenital heart disease Seizure disorder Anaemia Tachypnea of newborn Intestinal obstruction etc. Urinary tract infection Saha et al Am J Trop Med Hyg, 2018 Protein Energy Malnutrition Encephalitis 24

24 3000 cases of AGE 1500 RV cases ~700 cases will be prevented by Rotavirus Vaccine We will able accommodate at least 500 potential serious cases Mostly with meningitis, asphyxia and preterm Impact of Rota on the health systempossible impact of vaccine Senjuti Saha Pneumonia Severe perinatal asphyxia Acute gastroenteritis Pre-term low birth weight Neonatal sepsis Bronchiolitis Febrile convulsion Sepsis Neonatal jaundice Enteric fever Meningitis Nephrotic syndrome Dysentery Congenital heart disease Seizure disorder Anaemia Tachypnea of newborn Intestinal obstruction etc. Urinary tract infection Saha et al Am J Trop Med Hyg, 2018 Protein Energy Malnutrition Encephalitis 25

25 What are we doing now? Pre-vaccine Measuring the burden of AGE Proportion of cases with Rotavirus Keeping track of all refusal cases irrespective of clinical diagnosis Refused cases will be followed up and outcome will be recorded These will be used as baseline data Post-vaccine Vaccine impact will be measured based on the combination of admission and refusal data Not just based on the admissions from the administrative data as it was done in the past 26

26 22 One Step Further Consultation time Ranged from 48 sec to 22 mins We are aiming for it too! Consultation Time (min) Bangladesh Pakistan Nepal India Ethiopia Egypt Germany Zimbabwe UK Denmark Netherlands Japan Poland New Spain Australia Belgium Portugal Canada France Switzerland Russia Finland Norway Bulgaria USA Sweden Countries BMJ Open November 2017; 7(10): e

27 Conclusions Introduction of Rotavirus vaccine will prevent deaths and disabilities of non-rota cases - who are getting refused due to lack of beds Rota vaccine will facilitate the prevention of deaths and disabilities of the cases with meningitis, severe pneumonia and birth asphyxia, preterm babies Expedite the achievement of SDG3 New Strategy of Advocacy to convince policy makers Based on multi-dimensional changes in the world our advocacy to convince the policy makers need to be changed Need to focus on improvement of health system, not limiting to prevention of disease specific deaths This concept is not specific for Rotavirus vaccine but also other diseases like RSV, Typhoid, etc. 28

28 Acknowledgements 29