Rotavirus disease & prevention - the Indian context

1. Facilitator - Dr Gaurav Gupta

2.  A bit about diarrhea & ORS  Epidemiology & disease burden of Rotavirus  Efficacy of Rotavirus vaccine incl differences between Rotarix v/s Rotateq  Special issues with RV vaccines  CME

9. Almost every child infected by 2 years irrespective of Socio Economic Class Rotavirus is: Highly Contagious: Person to person, feco-oral, respiratory droplets Resistant to inactivation: Most soaps and disinfectants not effective Highly Stable: Retains infectivity for several weeks

11. Number of deaths due to rotavirus disease (and percentage of the global total) in 10 countries with the greatest number of deaths due to rotavirus disease. 23% of all deaths due to rotavirus disease occurred in India Adapted from: Umesh Parashar, Global Mortality Associated with Rotavirus among Children • JID 2009:200 (Suppl 1) • S9-15

13. Other G9P[6] 7% G9P[8] 1% 3% G4P[8] 9% G3P[8] 3% G2P[4] 12% G1P[8] 65% Other=untypeable and rare G-P combinations. 1. Santos N, Hoshino Y. Rev Med Virol. 2005;15:29–56. Reproduced by permission of John Wiley & Sons Limited.

14. IRSN Data G12 P[4][6][8], 6.5% G9 P[8], 8.5% G2 P[4], 25.7% G1 P[8], 22.1% Unique features: Diversity of rotavirus strains & mixed infections. Need for vaccines formulated against a broad range of strains.2 It is found that the predominant Rota Virus strain (type) in cities varied from year to year and from city to city. 3 1. The Journal of Infectious Diseases 2009; 200:S147–53. 2. Indian J. Med Res 118, Aug 2003, Pg 59-67 3. Journal of Clinical Microbiology. Oct 2001, Pg 3524-3529.

17. RISK EVENTS 1 in every 177-196 children 122,000-153,000 Deaths 1 in every 31-59 children 457,000-884,000 Hospitalizations 1 in every 13 children 2 million Outpatient Visits Estimated annual number and risk of death, hospitalization, and outpatient visits due to rotavirus diarrhea in children <5 years of age in India. Adapted from: J. E. Tate et al. Disease and economic burden of rotavirus diarrhea in India/Vaccine 27 S (2009) F18–F24

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22. Vaccines should mimic the natural infection  Predominance of individual serotypes pattern can vary from A multivalent vaccine is by geographic region.1 year to year and expected to give more  Primary infections are usually associated with diverse protection against multiple serotypes with the 1st dose more severe disease than subsequent infections.2 are expected to give good protection 2 doses against moderate to severe diarrheas  Protection against disease is thought to increase with each subsequent protection 2 3 doses are expected to give good infection. against mild diarrheas as well  Immunity following primary infection is thought to be predominantly serotype specific.2 1. Santos N et al. Rev Med Virol. 2005;15:29–56. 2. Velázquez FR et al. N Engl J Med. 1996;335:1022–1028.

23. SEROTYPE-SPECIFIC (HOMOTYPIC) Immune Response First infection elicited a HOMOTYPIC protective response Second & subsequent“CROSS-PROTECTIVE” infections (HETEROTYPIC) elicited a HETEROTYPIC protective response 1 2 3 Number of Infections (Graph for illustrative purposes only) • After primary infection, antibody response appears to be predominantly serotype specific (homotypic).1,2 • After subsequent infections, a broadened, cross-reactive (heterotypic) antibody response can occur.1,2 1. Cortese MM et al. MMWR Morb Mort Wkly Rep. 2009;58(RR02):1–25. 2. Jiang B et al. Clin Infect Dis. 2002;34:1351–1361.

39.  A 10-week-old boy born HIV positive  A 16-week-old adopted girl from unknown parentage  A 12-week-old premature stable boy in the neonatal intensive care unit  A 13-week-old girl who is breastfeeding

40.  A 10-week-old boy born HIV positive  A 16-week-old adopted girl from unknown parentage  A 12-week-old premature stable boy in the neonatal intensive care unit  A 13-week-old girl who is breastfeeding

42.  An infant with short bowel syndrome  An infant with HIV  An infant with severe combined immunodeficiency disease  An infant with spina bifida

43.  An infant with short bowel syndrome  An infant with HIV  An infant with severe combined immunodeficiency disease  An infant with spina bifida

44.  Mexico  Africa  Brazil  India

45.  Mexico  Africa  Brazil  India

46.  A full-term 5-week-old infant  A full-term 33-week-old infant  A full-term 16-week-old infant  A preterm 8-week-old infant

47.  A full-term 5-week-old infant  A full-term 33-week-old infant  A full-term 16-week-old infant  A preterm 8-week-old infant

48.  Hirschspung disease  HIV  Malabsorption syndrome  Severe combined immunodeficiency syndrome

49.  Hirschspung disease  HIV  Malabsorption syndrome  Severe combined immunodeficiency syndrome

50.  Intermittent fever, diarrhea, and abdominal pain  Low-grade fever, vomiting, and copious, watery diarrhea  Projectile vomiting, abdominal pain, and watery diarrhea  Vomiting, fever greater than 102°F, and intermittent diarrhea

51.  Intermittent fever, diarrhea, and abdominal pain  Low-grade fever, vomiting, and copious, watery diarrhea  Projectile vomiting, abdominal pain, and watery diarrhea  Vomiting, fever greater than 102°F, and intermittent diarrhea

52.  Between 8 weeks and 32 weeks  Between 6 weeks and 14 weeks, 6 days  Between 12 weeks and 24 weeks  Between 4 weeks and 14 weeks, 6 days

53.  Between 8 weeks and 32 weeks  Between 6 weeks and 14 weeks, 6 days  Between 12 weeks and 24 weeks  Between 4 weeks and 14 weeks, 6 days

54.  The ACIP, AAP & IAP recommend Rotarix® because it can be administered in a 2-dose series  The ACIP, AAP & IAP recommend RotaTeq® because it is more effective in preventing severe rotavirus disease  The ACIP, AAP & IAP recommend Rotarix ® when initiation of the vaccine series is delayed  The ACIP, AAP & IAP do not recommend one vaccine over the other

55.  The ACIP, AAP & IAP recommend Rotarix® because it can be administered in a 2-dose series  The ACIP, AAP & IAP recommend RotaTeq® because it is more effective in preventing severe rotavirus disease  The ACIP, AAP & IAP recommend Rotarix ® when initiation of the vaccine series is delayed  The ACIP, AAP & IAP do not recommend one vaccine over the other

56.  The benefit of preventing severe rotavirus gastroenteritis outweighs the small potential risk for intussusception  There is no risk for intussusception from rotavirus vaccination  No association between RV vaccines and intussusception has been observed in either pre- or postlicensure studies  RotaShield® was taken off the market, but not because of an association with intussusception

57.  The benefit of preventing severe rotavirus gastroenteritis outweighs the small potential risk for intussusception  There is no risk for intussusception from rotavirus vaccination  No association between RV vaccines and intussusception has been observed in either pre- or postlicensure studies  RotaShield® was taken off the market, but not because of an association with intussusception

58.  Concerns regarding RV burden in India?  Concerns regarding RV vaccine efficacy?  Concerns regarding LM / admission with AGE after RV vaccine?  Cost of vaccine  Side-effects of vaccine  Short window period for vaccination  Lack of patient awareness/ unable to convinve parents ?

Rotavirus disease & prevention - the Indian context

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Rotavirus disease & prevention - the Indian context

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