Champion Series

Fred Were, MD, PhD

University of Nairobi, Kenya

Closing child diarrhea wards: The impact of rotavirus vaccines in Kenya

For the latest ROTA champion spotlight, we had the opportunity to speak with Dr. Fred Were on the impact of rotavirus vaccines in Kenya. Dr. Were is a professor of pediatrics and child health and Dean of the School of Medicine at the University of Nairobi and has shared his expertise as a member of the WHO Strategic Advisory Group of Experts on Immunization (SAGE) and several national and regional immunization committees.

Why was there such a critical need to introduce a rotavirus vaccine in Kenya?

We knew from our data that diarrheal diseases consistently occupied the top end of the list of causes of both morbidity and mortality among children. We also knew that rotavirus was commonly isolated—there was local data that gave some quantification of the contribution of rotavirus to severe diarrheal disease. By the time the vaccine became available and conversations started from SAGE and WHO, Kenya had sufficient local information to be able to share that we have the disease, we know the impact, and if there’s an intervention, we shall be ready to do that.

How did you advocate for the implementation of rotavirus vaccine in Kenya’s immunization program?

We combined advocacy and activism to ensure the issue of rotavirus was known and that rotavirus vaccine was the only vaccine that contributes to reducing diarrheal mortality and severe disease.  

There wasn’t a single person practicing in Kenya who wasn’t aware of a child with diarrhea who died or who wasn’t aware of full wards set aside in hospitals for children with diarrhea. The fact that the disease and its consequences, especially death and hospitalization, were known to everybody made it easy for us in child advocacy.

We took advantage of the efforts towards achieving MDG 4 to drum up interest in the rotavirus vaccine. We set out to achieve MDG 4, reducing child mortality from 105 deaths to 32 per 1,000 live births. It was clear that we could not win that war without looking at diarrhea, and the easiest intervention among those that were not already in play were vaccines.

By the time rotavirus became a Gavi-obtainable vaccine, we had already made noise around the country, informed the public and the decision makers that if the vaccine ever becomes available, it is a good thing for us to adopt.

How was rotavirus vaccine received by the public?

The nuisance of having a child with diarrhea is something that nobody wants, so I think it was more welcomed than any vaccine in the past, tied with pneumonia [pneumococcal vaccines].  Everyone knew diarrhea was caused by germs and the fact that we could now do something about this one germ, rotavirus, made it easier to sort of sell to the people the need for rotavirus vaccine. Advocating for a vaccine whose disease is known—the syndrome is known in all our local languages, even dehydration is a word in Kiswahili—makes it easier than when you’re speaking about an illness that you are struggling to explain.

Were there any logistical challenges upon introducing rotavirus vaccines?

We lost four or five years preparing the cold space, a particular nightmare. We barely had enough space for the pentavalent vaccine and then we needed to make room for the rotavirus vaccine. [To accommodate rotavirus vaccine], we had a big cold chain expansion and considerable decentralization of storage.

What is rotavirus vaccine coverage like now in Kenya and have you been able to achieve and sustain high levels of coverage?

I wish I could say yes, yes, yes, but our coverage has stayed around 70%. Our target would be of course over 90% nationally—we do have regions that have very high coverage in excess of 90%.  

How has COVID-19 impacted rotavirus vaccine coverage?

COVID has impacted everything, including primary health care provision of ORS and zinc, since many of the non-emergency things sort of collapsed. During the first month of COVID all immunization programs were paralyzed because everybody was avoiding hospitals. Coverage certainly dropped quite a bit in 2020. We are now planning a recovery process, seeing how to bridge the gap, and using local data to inform outreach activities beyond the primary program. The fear of COVID remains but the confidence to go to hospitals is coming back.

For other countries that have yet to introduce the rotavirus vaccine, what advice would you give them?

I’d invite them to come visit our primary level hospitals and see wards that closed since rotavirus vaccine came around. The severe disease just almost disappeared. My advice would be to not just concentrate on mortality prevention, which is harder to measure, but look at protection to the health system that rotavirus vaccines bring about.

Beyond preventing severe diarrheal disease, what other benefits of rotavirus vaccination have you seen in Kenya?

The biggest impact of rotavirus or any severe diarrheal disease is how it disrupts the rest of the child’s health, making children more prone to malnutrition and other issues. Part of what has reduced the massively severe life-threatening malnutrition we used to see is the fact that severe diarrhea is a lot less common. So, the impact of rotavirus vaccine in reducing severe diarrhea has other advantages.