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Childhood deaths from diarrhea reduced in Brazil after rotavirus vaccine added to immunization schedule
Do Carmo GMI. PLoS Med. 2011;doi:10.1371/journal.pmed.1001024.
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Substantial reductions in diarrhea-related deaths and hospitalizations in children aged 5 years and younger were recorded in Brazil after the nationwide addition of the rotavirus vaccine to the immunization schedule.
Manish Patel, MD, and colleagues from the CDC conducted a time-series analysis of Brazilian national data collected before and after the Brazilian Ministry of Health introduced the rotavirus vaccination in July 2006; diarrhea-related mortality or hospitalization rates were the main outcome.
The researchers compared monthly mortality and hospital admission rates estimated for 2007 to 2009 (the years after the vaccination was added) with the expected rates calculated from 2002 to 2005 (pre-vaccine years) and adjusted for seasonal trends. Because age substantially affects disease rates and vaccine coverage during the beginning years of immunization programs, the researchers also studied changes in diarrhea-related death and hospitalization death rates by age groups (younger than 1 year, 1 to 2 years, 2 to 4 years).
From 2007 to 2009, diarrhea-related mortality and hospitalizations among children aged 5 years and younger were 22% (95% CI, 6-44) and 17% (95% CI, 5-27) lower than expected, respectively; approximately 1,500 fewer diarrhea deaths and 130,000 fewer diarrhea-related hospital admissions were recorded in this cohort.
The largest reduction of death (22%-28%) and admission (21%-25%) rates were found in the group aged 2 years and younger, which also had the highest rates of vaccination. Among children aged at least 2 years — the cohort not age-eligible for vaccination during the study period — lower reductions in deaths (4%) and admissions (7%) were observed. From 2007 to 2009, there were approximately 130,000 fewer diarrhea-related hospitalizations recorded in Brazil than expected, in the absence of vaccination among children aged 5 years and younger.
“Prevention of rotavirus-related admissions is particularly important for middle- and high-income countries in which nonfatal rotavirus diarrhea is a common cause of childhood morbidity,” the investigators wrote. “The results from Brazil suggest protection of rotavirus vaccination against both diarrhea deaths and diarrhea-related hospital admissions, adding to the strength of evidence supporting investment in rotavirus vaccination to curtail the 1.3 million deaths and 9 million hospital admissions related to diarrhea that occur annually worldwide.”
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From 1999-2005, more than 5 million children died from the complications of rotavirus gastroenteritis, translating into an annual mortality of 527,000 children aged younger than 5 years, (WHO Weekly Epidemiological Report 82[32]). In 2006, rotavirus immunization programs were introduced in the Americas and Europe with excellent vaccine uptake and a notable decline in hospitalization rates due to rotavirus and all cause hospitalization for diarrhea. The WHO published a position paper in December 2009 recommending that oral rotavirus immunizations be included in all national immunization programs. Rotavirus immunization was strongly recommended in countries where diarrheal mortality accounts for greater than 10% of deaths in children aged younger than 5 years (WHO Weekly Epidemiological Report 84 [51-52]).
Surveillance studies such as the one conducted by these authors documenting a reduction in the burden of diarrheal disease before and after vaccine introduction are extremely important as they provide an opportunity to measure the impact and justify an intervention. Additionally, ongoing surveillance assists with evaluation of vaccine safety and facilitates monitoring changes in rotavirus epidemiology. Brazil is fortunate to be the home of one of the WHO regional rotavirus reference laboratories, facilitating surveillance efforts.
Fourteen percent (27 of 193) WHO member states have introduced rotavirus vaccines into their immunization programs as of April 2011 (MMWR 60 [16]). Barriers to incorporation include the cost of the vaccine and limited resources for distribution. These may be minimized with local manufacture and the devotion of resources to maximize uptake. Studies such as this one by Patel and colleagues reinforce the importance of surveillance to document the benefits of vaccine introduction, and solidify the importance of rotavirus vaccine as an effective prevention measure to reduce the burden of diarrheal disease.
-Andi L. Shane, MD, MPH, MSc
Infectious Diseases in Children Editorial Board member
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