Bangladesh: How to move from data to implementation. K. Zaman, MBBS, PhD Senior Scientist and Epidemiologist icddr,b

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1 Bangladesh: How to move from data to implementation K. Zaman, MBBS, PhD Senior Scientist and Epidemiologist icddr,b

2 Rotavirus in Bangladesh Estimated 2.4 million cases of rotavirus diarrhoea annually in children <5 years of age 40,000 hospitalizations for rotavirus AGE at icddr,b hospitals each year ~ 40% of diarrhea hospitalizations in children Represents about 15% of community cases (0.5/child/year) Up to 3,000 deaths in children <5 each year

3 Rotavirus in Bangladesh Year-round transmission, with seasonal peaks January-February winter peak similar to US July-August summer peak during monsoon icddr,b Matlab 200 Number J an F eb Mar Apr May J un J ul Aug S ep Oct Nov Dec Months Zaman et al, Vaccine

4 Co-administration of Rotavirus (Rotarix) and oral polio vaccine

5 Anti-RV serum IgA antibody response at 1 month post-dose 2 (Rotarix study) Seroconversion rate % Treatment group N n P value (95% CI) RIX OPV (44; 68) RIX (54; 78) Placebo + OPV (8; 36) Placebo (7; 35) Placebo - pooled (10; 30) Seroconversion rate, cut-off 20U/ml Zaman et al, Vaccine 2009

6 % Seroconversion GMT Lower rotavirus immunogenicity when rotavirus vaccines given concomitantly with polio in the EPI schedule RV IgA seroconversion RV IgA geometric mean titer p < p < Concomitant Staggered 0 Concomitant Staggered Emperador Zaman et al CID, 2015

7 Seroprotection rates for anti-poliovirus types 1, 2 and 3 antibodies Antibody Anti-poliovirus type 1 Timing RIX OPV RIX4414 Placebo pool Seroprotection rate % (95% CI) 86.4 (76;94) 92.8 (84;98) 90.1 (81;96) Anti-poliovirus type 2 RIX OPV RIX4414 Placebo pool 98.5 (92;100) 92.9 (84;98) 97.1 (90;100) Anti-poliovirus type 3 RIX OPV RIX4414 Placebo pool 69.6 (57;80) 73.5 (61;84) 68.1 (56;79) RIX Rotarix vaccine Zaman et al, Vaccine 2009

8 Efficacy of pentavalent rotavirus vaccine against severe rotavirus gastroenteritis in infants in Bangladesh: a double-blind, placebocontrolled trial The Map Showing Villages of Matlab Study Area Gumti river D35 VB3 D34 Legend Comparison area Embankment > ICDDR,B Hospital in Matlab Intervention area Main river Village boundaries D98 VB4 D88 D97 D89 VB8 D96 D90 VB6 D95 VB5 D94 V96 V50 VB7 MEGHNA RIVER VB0 V51 Dhonagoda river V09 D99 V53 C00 A00 D93 V95 B00 D33 V97 V99 D30 V48 V98 V68 D32 VB1 VB2 V47 D28 V73 V38 D29 V80 V75 V90 V46 V71 V65 V45 V79 V76 D31 V49 V74 V66 V64 V78 V35 V40V39 V44 V42 P00 V43 V57 R00 DX1 V41 V34 Q00 O00 V33 V63 V89 S00 DX0 V67 M00 V30 V36 K00 V29 N00 V55 V84 V54 V17 T00 L00 V18 V07 V52 V81 V25 V28 VBA V08 V15 V16 V86 V24 V27 G00 V14 V23 V88 V06 H00 V85 V26 F00 V22 V87 V05 J00 V19 U00 V21 V02 V82 V01 V04 V03 V20 V83 W00 VBB D00 V12 > V56 V11 V59 V13 V61 V62 VBC V10 V60 V72 V32 V31 E GIS unit, ICDDR,B KM

9 Efficacy of RotaTeq Against severe RVGE of Any Serotype, Matlab Years Follow-up (personyears) Number of Severe RVGE Cases Efficacy (%) 95% CI Vaccine Placebo Vaccine Placebo First Year Second Year Overall RVGE- Rotavirus gastroenteritis Zaman et al, Lancet 2010

10 Severe RVGE Cases per 100 Vaccinees Efficacy and severe RVGE cases prevented through the first year of life cases prevented 2.5 cases prevented Placebo Vaccine cases prevented Asia Bangladesh Vietnam Zaman et al, Lancet 2010

11 Rotarix effectiveness study Introduction of a live, oral human rotavirus vaccine (Rotarix) in Matlab, Bangladesh

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13 Overall effectiveness of HRV Rotavirus Villages Non-Rotavirus Villages Cases (n) Incidence a Cases (n) Incidence a All ARD Severe ARD Vaccine Effectiveness, Adjusted b (95% CI) 29.0 (11.3, 43.1) 22.9 (-0.2, 40.7) a Incidence per 100 person-years. b Adjusted Vaccine Effectiveness using modeled using Poisson regression model Zaman et al, 2016

14 Total effectiveness of HRV Rotavirus Villages Non-Rotavirus Villages Vaccine Cases (n) Incidence a Cases (n) Incidence a Effectiveness, Adjusted b (95% CI) Any severity- all ages (23.2, 55.2) Onset <12 months (26.3, 59.3) Onset 12 through 23 months (-15.6, 56.3) a Incidence per 100 person-years. b Adjusted Vaccine Effectiveness using modeled using Poisson regression model Zaman et al, 2016

15 Total effectiveness by RV strain Total effectiveness, HRV Villages Non-HRV Villages Cases (n) Incidence a Cases (n) Incidence a G1P[8] G2P[4] G9P[8] G12P[6] G12P[8] VE, Adjusted b (95% CI) 54.5 (18.7, (-42.4, 79.4) 20.0 (-44.7, 55.8) 36.4 (-39.3, 71.1) 51.5 (18.5, 71.1)

16 Non-interference of concomitant administration of measles-rubella and rotavirus vaccines at 9 months of age in Bangladesh Measles Rubella Seroconversion Measles/Rubella and Rota vaccine (n=227) Measles/Rubella vaccine (n=233) Age n % 95% CI n % 95% CI 9 mon * * *Difference = 1.1 ( 6.9 to 9.0), P = 0.87 Zaman et al, J Infect Dis

17 Hospitals RMCH Proportion of children aged <5 years with AGE and RV positive and number of intussusception cases aged <2 years, by hospital July 12 -June 16 AGE cases Sampled RV positive (%) Intussusception cases 6,769 1, JIMCH JRRMCH LAMB BBMH JGH SBMCH RpMCH Total 22,203 5, Source: Dr. Satter, HBRIS report

18 Intussusception in Bangladesh Hospitalization of children for intussusception is uncommon Source: Dr. Satter, HBRIS report

19 House hold costs for treatment of rotavirus illness Cost items Rotavirus positive cases (n= 162) Rotavirus negative cases (n=55) Medical (Consultation fee, medicine, diagnostic tests etc,, Non-medical (Transportation, registration, bed, cabin, food etc.) Indirect costs Total costs 83.5 (US$) 62.5 (US$) Source: Jahangir M Khan (unpublished)

20 Meeting summary with EPI, Gob personnel, pediatricians, WHO, unicef and orther stakeholders All participants agreed to incorporate Rotavirus vaccine in EPI program Limited cold space has been identified as the most important barrier Meeting needs to be held among pediatricians to understand their views Type of Rota vaccine to be introduced in the EPI will be decided by National Immunization committee Program feasibility for Rotavirus introduction taking into account monitoring of intussusceptions will be continued. 20

21 Summary (contd.) RV immunization can prevent 5% of all childhood deaths and 40% of all deaths due to diarrheal disease Estimated to 2.4 million episodes and prevent about 135,000 hospitalizations due to severe rotavirus diarrhea in a year in Bangladesh A single episode of rotavirus costs US$ 84 which is 85 percent of the average Bangladeshi family s monthly income The total cost of rotavirus hospitalizations estimated to be US$ 66.8 million (about 500 crore Taka) each year WHO consultant has been working to finalize the application to GAVI by tomorrow for introduction in the EPI 21

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