Effectiveness of a monovalent rotavirus vaccine in infants in Malawi after programmatic roll-out: an observational and case-control study

Abstract

SummaryBackgroundRotavirus is the main cause of severe acute gastroenteritis in children in Africa. Monovalent human rotavirus vaccine (RV1) was added into Malawi's infant immunisation schedule on Oct 29, 2012. We aimed to assess the impact and effectiveness of RV1 on rotavirus gastroenteritis in the 2 years after introduction.MethodsFrom Jan 1, 2012, to June 30, 2014, we recruited children younger than 5 years who were admitted into Queen Elizabeth Central Hospital, Blantyre, Malawi, with acute gastroenteritis. We assessed stool samples from these children for presence of rotavirus with use of ELISA and we genotyped rotaviruses with use of RT-PCR. We compared rotavirus detection rates in stool samples and incidence of hospital admittance for rotavirus in children from Jan 1 to June 30, in the year before vaccination (2012) with the same months in the 2 years after vaccination was introduced (2013 and 2014). In the case-control portion of our study, we recruited eligible rotavirus-positive children from the surveillance platform and calculated vaccine effectiveness (one minus the odds ratio of vaccination) by comparing infants with rotavirus gastroenteritis with infants who tested negative for rotavirus, and with community age-matched and neighbourhood-matched controls.FindingsWe enrolled 1431 children, from whom we obtained 1417 stool samples (99%). We detected rotavirus in 79 of 157 infants (50%) before the vaccine, compared with 57 of 219 (40%) and 52 of 170 (31%) in successive calendar years after vaccine introduction (p=0·0002). In the first half of 2012, incidence of rotavirus hospital admission was 269 per 100 000 infants compared with 284 in the same months of 2013 (rise of 5·8%, 95% CI −23·1 to 45·4; p=0·73) and 153 in these months in 2014 (a reduction from the prevaccine period of 43·2%, 18·0–60·7; p=0·003). We recruited 118 vaccine-eligible rotavirus cases (median age 8·9 months; IQR 6·6–11·1), 317 rotavirus-test-negative controls (9·4 months; 6·9–11·9), and 380 community controls (8·8 months; 6·5–11·1). Vaccine effectiveness for two doses of RV1 in rotavirus-negative individuals was 64% (95% CI 24–83) and community controls was 63% (23–83). The point estimate of effectiveness was higher against genotype G1 than against G2 and G12.InterpretationRoutine use of RV1 reduced hospital admissions for several genotypes of rotavirus in children younger than 5 years, especially in infants younger than 1 year. Our data support introduction of rotavirus vaccination at the WHO recommended schedule, with continuing surveillance in high-mortality countries.FundingWellcome Trust, GlaxoSmithKline Biologicals.

Rotavirus vaccine effectiveness in low-income settings: An evaluation of the test-negative design

“…In Malawi, RV1 effectiveness for severe rotavirus-positive diarrhea during the first year of life was similar using test-negative controls and community controls (VE-TND: 68%, VE-Community controls: 68%) [17]. In South Africa, RV1 effectiveness for hospital admission with rotavirus-positive diarrhea in children <2 years old was comparable using test-negative controls and hospitalized controls (VE-TND: 57%, VE-Hospital controls: 63%) [20].…”

“…Further evidence of the accuracy of the test-negative control group is demonstrated in rotavirus vaccine case-control studies using multiple control groups in sub-Saharan Africa and Latin America [17], [19], [20], [23], [29]. In Malawi, RV1 effectiveness for severe rotavirus-positive diarrhea during the first year of life was similar using test-negative controls and community controls (VE-TND: 68%, VE-Community controls: 68%) [17].…”

“…The TND is being increasingly used to estimate rotavirus vaccine effectiveness in middle- and low-income settings due to its low cost and feasibility,[16], [17], [18], [19], [20], [21], [22], [23], [24], [25], [26] but little has been done to assess this epidemiologic study design in the context of rotavirus vaccine effectiveness in low-income settings. In the present analysis, RCT databases for RV1 and RV5 in sub-Saharan Africa and Asia were used to evaluate the TND.…”

Effect of pentavalent rotavirus vaccine introduction on hospital admissions for diarrhoea and rotavirus in children in Rwanda: a time-series analysis

“…[50][51][52] We report the fi rst data for the eff ect of routine RV5 vaccination in Africa. The strong seasonal peaks in hospital admissions for diarrhoea combined with a high rotavirus detection rate in the prevaccine period help accentuate the eff ect of the vaccine, as most of the reduction in diarrheal disease happened during these seasonal peaks.…”

Typhoid conjugate vaccines: making vaccine history in Africa

“…Considering 36 of the 47 GAVI-eligible countries are within Africa, this presents a huge opportunity for the continent. Looking at recent introductions of new vaccines into the continent, rotavirus and pneumococcal conjugate vaccines have been introduced into 29 and 33 different GAVI-eligible African countries, respectively, often ahead of schedule and demonstrating significant impact on disease burden [24][25][26].…”