“Advocacy for immunization support must go beyond the vaccine introduction.”

How did rotavirus first become a priority in Ghana?

We were one of the first on the continent to work on rotavirus after its discovery in 1973. Everyone thought severe gastroenteritis was just [caused by] bacteria. There were a lot of antibiotic prescriptions given out. We trained other budding scientists to diagnose rotavirus.

What has been your role in rotavirus vaccine advocacy in Ghana?

In the past it‘s taken about 13 years for vaccines to be brought to Africa [after being introduced in high-income countries]. We needed to shorten that. And so, with Duncan Steele, we set up the African Rotavirus Network, sharing, collecting, and using our data. Then data from clinical trials showed that yes, [rotavirus] vaccines worked in Ghana. The data from the clinical trials and the “country-owned” evidence-based data on rotavirus epidemiology and burden of disease was critical for the advocacy and demand for the vaccine when it was available.

How did you work to implement rotavirus vaccines?

We set up a small team involving scientists, policymakers, and food and drugs authority. Every region had its own peculiarity, and forming these groups allowed us to tease out some of those things. Challenges included:

• Vaccine storage: the government, UNICEF, and other partners helped expand storage.

• Accessing hard-to-reach areas, especially during rainy seasons: Our Community Health and Education Initiative Program helped ensure we could reach here.
• Product switch: We are doing our final training for the ROTAVAC and plan to rollout before the end of the year (2020). Because of the multi-dose vials, the vaccine storage space is now reduced.

After the second year of immunization and we brought hospitalizations [for gastroenteritis in children <5] down about 49%—that was amazing. My friends who are clinicians in hospitals say they are not seeing severe diarrhea in their wards. Although people still get diarrhea, it is not severe enough to warrant hospitalization.

What are the challenges to communicating about rotavirus vaccines?

I’ve never liked the top down approach. We need to engage with people, using data that we have generated for them.

We told mothers and caretakers that rotavirus vaccine will prevent severe diarrhea due to rotaviruses. However, it doesn’t prevent all diarrhea. If you tell them it prevents all diarrhea, and they get diarrhea, they think “oh your medicine doesn’t work.” So, you must be very clear that it prevents severe diarrhea caused by this virus.

How do you retain high levels of trust in immunization?

If there is an issue, tell them the truth, and discuss with them how you are solving it. But if you hide it from them and they find out, then that’s it, they’ll never trust you again. Vaccination and immunization is about trust and believing in you.

The vaccination card for the child is something that mother’s hold dearly to their hearts. Of late, we’ve had some anti-vax advocates create a presence, but the funny thing is that they started with measles. Mothers know the impacts of the measles vaccination on their children, so the anti-vaxxers did not have much influence.

What are your priorities today related to rotavirus vaccine?

Advocacy doesn’t end with introduction, it must always continue. My biggest concern has always been with sustainability: Without Gavi support, will countries sustain it?

We are now gathering a lot of data on the economic impact––showing how much you spend if you take off vaccination, and how much you save because of vaccination. There are a lot of cost benefits. You save on hospitalizations, on your hospital attendants, you save on laboratory tests, you save on critical care from other areas. We need to convince politicians by gathering this information then put it into a form that is easy to understand.

We are also planning a study to look at the potential impacts of the vaccine switch.

How has the pandemic affected routine immunization and rotavirus vaccine coverage in Ghana?

For the first three months or so, people were scared of getting infected when going out to hospitals so mothers were not taking their kids there. The EPI attendance fell about 30%, and rotavirus was definitely affected.

The Rotarix Rotavirus vaccine is administered at 6 and 10 weeks, which means that once you go past that, you may miss a window. Because of this, rotavirus coverage came down about 60%, but over the past 3 months, we’ve worked to get the coverage back up to 80%, still down from 93%, what it was in 2019.

The ministry did a really great job of reassuring people that with all the necessary precautions––wearing masks, washing hands, maintaining distance––the chances of getting infected are pretty low. When you get to the immunization clinic, everything is well-spaced out, an open environment, so the chances of getting infected are minimized.

Any final thoughts on rotavirus vaccine advocacy that you would like to share?

I hope every child can get vaccinated. It would be a shame if we deny any child the chance of getting vaccinated, to get a better life in the future.

The Discovery of Rotavirus

Australia has played a critical role in combatting rotavirus illnesses and deaths worldwide for more than 40 years. In 1973, Australian virologist, Dr. Ruth Bishop, and her team of researchers at the Royal Children’s Hospital in Melbourne first identified the virus. Following on Dr. Bishop’s groundbreaking discovery of the virus, similar studies reported the presence of the virus in diarrheal patients around the world. Two decades after her discovery, Dr. Bishop recalled “it was like pressing a whole lot of light bulbs on a world map… Everyone was saying ‘we have found the virus too.’”

Dr. Julie Bines, a ROTA advisor and a clinician and researcher at the University of Melbourne, was taught and mentored by Dr. Bishop and worked with her for many years. Speaking with Dr. Bines for our Champions Series, she spoke of her rotavirus vaccine advocacy — engaging with opinion leaders and media and presenting to clinicians the severity of rotavirus and benefits of the vaccine. Australia introduced rotavirus vaccines in 2007, an introduction Dr. Bines referred to as being “relatively straightforward with early acceptance from clinicians and public.” Dr. Bines reflected that “part of what made introducing rotavirus vaccines in Australia an easy consideration [was the] demonstrated burden of rotavirus hospitalizations and cost-effective analysis.”

Rotavirus Vaccine Cost Savings

Analyses from 2007-2012 have shown that rotavirus vaccines achieved cost savings for Australia to the tune of A$66 million over the six-year period, a positive outcome that cost-effectiveness analysis did not predict. The unexpected cost savings were due in part to the indirect effects of vaccination—a reduction in rotavirus in older children, often diagnosed as unspecified gastroenteritis.

Continuing Challenges

Rotavirus vaccine coverage in Australia has reached 87% as of 2019, an achievement Dr. Bines largely attributes to “community acceptance of the value of vaccines [and a] strong public health system with funding to support the national immunization program.” Despite the convincing evidence for Australia to implement rotavirus vaccines, challenges persist. Dr. Bines notes the importance of transparency in gaining the public’s trust and support, highlighting how the benefits of rotavirus vaccination greatly outweigh the very small risk of intussusception: “putting in context the justification of continued vaccination … recognizing and prompt treatment of intussusception if this occurs.”

In addition, vaccine hesitancy is a growing issue threatening immunization programs, including rotavirus vaccines. Dr. Bines commented on the challenge to sustain high vaccine coverage noting, “media attention on anti-vaccination lobbies and high profile celebrities making confusing statements have not been helpful in efforts to prevent potentially life-threatening diseases through vaccination.”

The COVID-19 pandemic has compounded immunization challenges across the globe as routine immunization programs are being disrupted, people are hesitant to risk going out into clinics, and overall attention is concentrated on the pandemic. Dr. Bines recognizes the “challenge advocating during the pandemic, stressing the importance to continue routine vaccination programs.” To avoid undoing years of progress in routine immunization and child health, Dr. Bines suggests we “continue to stress the importance of routine immunization [and] provide reassurance of the balance of risks with attending the immunization clinic.” The current COVID-19 crisis further underscores the importance of the work done by pioneers like Dr. Ruth Bishop and scientists and champions such as Dr. Julie Bines.

In recent years, Dr. Bines has been leading a team at the Murdoch Children’s Research Institute in developing a new rotavirus vaccine that utilizes a birth dose strategy to target early prevention of rotavirus and potentially overcome other remaining barriers to vaccine implementation. The legacy of Dr. Bishop remains palpable as this new low-cost, neonatal rotavirus vaccine, called “RV3-BB”, is based on the strain originally identified by Dr. Bishop.

“You cannot advocate without learning first. You must listen to people and learn from people and see what is right for your people because it will differ from country to country.”

Has the Philippines decided to introduce rotavirus vaccination?

Rotavirus was first introduced in the national immunization program (NIP) in 2012. We were the first in Asia to do so. During that time, we could not reach everyone because our birth cohort was around 2.4 million children and at that time, we really only had the funds to give the vaccination to around 300,000 children. The Secretary of Health had funds to give to at least 1/4th of the children who would need it or 1/4th of the target population. So what they did was give it to the poorest 25th percentile of children. The children – the poorest – at the highest risk of dying were given some kind of defense, some kind of privilege that could actually save their lives.

Why was it so crucial to introduce rotavirus vaccination at that time?

In 2005/2006, I learned about the Asian Rotavirus Surveillance Network, which confirmed out previous studies and published research on the etiology of acute diarrhea in children. Our research found that 41% of Asian children with diarrheal disease are due to rotavirus. I had done previous research in ORS (Oral Rehydration Salts) with WHO as well as research on the etiology of acute diarrhea sometime in the 90s, so I had already been convinced rotavirus was there. However, this ARSN study is what really sparked wider interest in rotavirus. We had to convince the Secretary of Health that there was justification for introducing the rotavirus vaccine and at the time he was being pressured to achieve the Millenium Development Goal 4 (MDG4) which calls for the reduction of morbidity and mortality, so I think that was the main reason rotavirus vaccine was finally being considered.

How was rotavirus made a priority?

In order to make rotavirus a priority, it was important to educate the secretary of health about rotavirus and the vaccine. The first time I talked with the Secretary of Health about rotavirus he started with “Oh but with diarrhea, all we need is to get clean water supplied to everyone.” I told him in a 5-minute elevator pitch that altogether, yes, clean water is good, but diarrheal disease from rotavirus isn’t affected much by hygiene and sanitation. While these two factors are important, they cannot prevent rotavirus – think about why the United States of America has it on its National Immunization program.

This conversation was two weeks after he was appointed Secretary of Health, and he really tried to learn and study what would be best for the children.

How did you advocate for rotavirus vaccines?

In 2000, with some friends, I set up the Philippine Foundation for Vaccination. People were only aware of the essential vaccines and ought to know also about these new vaccines. We wanted to become the voice that would raise awareness on the value of vaccination. In line with Gavi, I thought, yeah this is it – this is what we need to do to sustain and even strengthen vaccine coverage in the Philippines. That was the start.

Inspired by the annual national immunization conference hosted by the CDC in the US, our foundation started the same for the Philippines. In all our national immunization conferences we would always invite the Secretary of Health as a keynote speaker because I knew from the very start that vaccination was always a public health issue. And so, we had to get the public health professionals to be part of our national immunization conference. We knew the department wasn’t getting a lot of these updates on new vaccines or even what a booster was, so we knew we had to involve the health officials in national immunization conferences so they would be updated and educated.

What was the biggest logistical challenge you faced in getting the rotavirus vaccine implemented?

Vaccines are used by so many people because it has a great public effect, but even so, a change in administration can affect the way vaccines are prioritized. With competing interests from other activities, vaccinations started to become criticized for receiving the most funds.

Another issue that had a lasting impact on implementing rotavirus vaccines and other vaccines was the Dengvaxia chaos which caused vaccination programs to stop because of political issues and difficulties. It was really too bad that vaccine coverage and vaccine confidence went down in the Philippines. That led to outbreaks a year later. In 2019, deaths from measles were as high as more than 500 when in fact we didn’t have any deaths from 2005 to 2010 and it was almost eliminated – measles came back with a vengeance.

Have there been challenges with rotavirus coverage during COVID?

We have seen our immunization coverage decrease. Particularly, in areas with the highest COVID incidence, you have the lowest vaccine coverage. Even in the booster for measles, we used to see 80% coverage and now we are down to less than 50% and maybe even 30%. Mothers are scared to go to hospital clinics for vaccinations and transportation is limited and even non-existent in some cases. We are also still suffering from the Dengvaxia backlash and there is still a lot of vaccine catch-up that is needed.

How have you overcome struggles presented by the COVID-19 pandemic?

Personally, I have been organizing webinars for sharing information on innovative and strategic ways to increase vaccine coverage both in the public and private sectors. Social distancing is a major challenge and the need to ensure the use of protective measures for health front liners and patients has been very important. We have implemented drive-thru vaccination sites, the use of basketball courts for vaccination, house-to-house vaccination by the departments of health, and even vaccination by pharmacists in order to maintain coverage.

Do you have any final advice on rotavirus vaccine advocacy that could help other countries hoping to introduce the vaccine?

You need good training and a really passionate and evidence-informed advocacy group. You have to be informed about what evidence is available so that you can engage different stakeholders in an educational way. Not influential – because people always say ‘you have to influence them’. No, it’s not influencing them, but educating them, and in a way that you are learning from and helping each other. You cannot do advocacy without learning first. Listening to people, learning, and seeing what is right for your people because it will be different from one country to another. Having a group or, even better, multiple groups is important because creating a difference is always best when you have someone to converse ideas with.

Communication is also very, very, very essential. It’s important to learn to communicate and explain things so that people will understand. And of course, be friendly with the media.

“Maintaining high coverages has been particularly challenging because messages highlighting the importance of vaccination at public health units are often lost among the dominant messages to stay at home and avoid overwhelming our public health capacity.”

Introducing rotavirus vaccine in Brazil was critical

Since we first detected rotavirus in 1976, I have been actively involved in researching viral infections in the Amazon region. One of the first reports of rotavirus was actually in Indian communities. The Air Force of Brazil notified us in 1977 about an outbreak of diarrhea in the Tiriyó Indians, an isolated group in the north of Pará state near the border with Suriname, and the Air Force medical relief team flew to the village to respond. The attack rate was very high: 157 of 224 Indians at risk had diarrhea. Of the samples we tested, 76% were positive for rotavirus antibodies. Although all ages were affected, children were particularly prone to severe disease.

Rotavirus was a leading cause of severe gastroenteritis with estimations of more than 800,000 cases and 2,400 deaths annually in Brazilian children under 5. Additionally, studies showed that universal vaccination would result in total medical savings of US$19.3 million.

I led phase 2 and 3 trials of Rotarix in Belém, Brazil. We shared results—the vaccine provided high protection (~85%) against severe rotavirus disease—in interviews with radio, television, and others. In light of these results, Brazil was the first Latin American country to launch rotavirus vaccination into the public sector in March 2006, purchasing the vaccine through PAHO’s Revolving Fund. We sustained high levels (≥80%) of rotavirus vaccine coverage from 2007 to 2018, even though rates have been consistently lower when compared to those of established vaccines (e.g. DTP-Hib). This difference is likely due to insufficient health care worker education and information, supply interruptions, inadequate cold chain capacity in rural/remote areas, and missed immunization opportunities.

During the first years following introduction, a substantial number of children were excluded from rotavirus vaccination due to strict age restrictions that were eventually lifted by the WHO in 2013. The adoption of this new policy by the Brazilian Ministry of Health’s National Immunization Technical Advisory Committee was of great importance programmatically and has helped in successfully integrating rotavirus into NIP.

Vaccine hesitancy threatens program success

In 2019, seven vaccines in Brazil showed a significant reduction in doses applied when compared to 2018, all of which being used for childhood vaccination, including rotavirus vaccine. Leading the charge in this reduction were false “scientific facts” (e.g., that children developed cow’s milk protein allergy after rotavirus vaccination) spreading rapidly through social media. We can educate future generations about scientific methodology and evidence-based medicine and health, leading them to critically evaluate the veracity of the information they get from social media.

Other factors for lower coverage include reductions in funding dedicated to the Brazil’s Unified Health System, Sistema Único de Saúde, as well as political conflicts, socioeconomic collapse, and difficulties in bringing vaccines to remote areas such as Indian and rural communities.

COVID-19 pandemic has further eroded vaccine coverage

It is much more difficult to advocate for rotavirus vaccination and other childhood vaccinations during these challenging times of the rapidly evolving COVID-19 pandemic in Brazil—which is [as of 24 August 2020] causing 1,000 deaths per day.

On average, only ~50% of Brazilian children have received rotavirus vaccine from January – June 2020. Reasons include:

• severe public health system constraints
• physical distance measures to mitigate the spread of the coronavirus pandemic
• community reluctance to visit vaccination health units for fear of contracting SARS-CoV-2 infection

Many people in Brazil were prevented from accessing treatments for non-COVID infectious diseases, including diarrhea, due to strict controls on movements, avoidance of crowded waiting rooms, and other measures to curtail the pandemic. Pediatricians and public health units in Belém where treatment for diarrhea is routinely provided remained closed during the lockdown periods due to new strategies adopted during the pandemic that focused mainly on patients affected by COVID-19.

An additional challenge in Brazil is the current atypical situation at the Ministry of Health, where the most recent Health Minister resigned on 15 May 2020, just four weeks after joining the government administration. Until September 2020, there has been an Interim Minister at Brazil’s Ministry of Health in parallel with the loss of other key team members at the MoH’s headquarters in Brasília.

We need to adopt urgent actions to overcome the challenges posed by the COVID-19 pandemic

Brazil is making efforts to follow the recently issued Pan American Health Organization guidance on the operation of immunization programs. With lockdown restrictions easing, vaccination posts will open for extended hours to avoid crowds. However, these actions mostly target vaccinations against flu, measles, and yellow fever in municipalities where these diseases are circulating. As of now, it is still not clear whether rotavirus vaccination will be included among these urgent actions taken while restrictions to movements persist.

Maintaining high coverages has been particularly challenging because messages highlighting the importance of vaccination at public health units are often lost among the dominant messages to stay at home and avoid overwhelming our public health capacity.

Nonetheless, I think clearer national government messaging in informing the importance of maintaining high uptake of routine vaccinations is needed.

“The challenge now is to get children up to date on their shots by bringing the vaccines out of the medical units and into safe, open air public places.”

What data signaled the need for rotavirus vaccine in Mexico?

When I joined the National Center at the end of 2006, rotavirus was a large burden to the health system and a major cause of death in young children. Diarrheal disease was the fourth leading cause of hospitalizations in children <5 and the second leading cause of outpatient medical visits.

What’s more, 7% of all deaths in children <5 were due to diarrheal disease—up to 2,000 deaths per year. At least 4 out of 10 of these deaths were due to rotavirus.

Although there was a marked reduction in deaths since Mexico introduced oral rehydration, and when water chlorination became mandatory in 1990, there were still peaks of deaths, especially during the winter. Deaths plateaued until we introduced rotavirus vaccine.

Did you know? WASH interventions are critical to reduce diarrheal disease cases, hospitalizations, and deaths, but only rotavirus vaccines will prevent this form of severe diarrheal disease, prevalent in low- and high-income countries alike in the absence of vaccination.

How did advocates make a case for rotavirus vaccination in Mexico?

As the head of Mexico’s National Center for Child and Adolescent Health, my role was to advocate with input from a group of national experts. We gathered evidence to support universal introduction of rotavirus vaccine, not only in the poor municipalities but for all children under a year old. Advocacy from the Minister and the vice minister really made a difference and the vote to introduce rotavirus vaccine was unanimous at the National Vaccination Council.

How did you fund the rotavirus vaccine?

Mexico had a Minister of Health that besides being a public health expert was a great economist, and he had figured out that there should be a pocket of resources from cigarettes, soda, and junk food taxes to allocate for public health measures. This idea may help other countries: tax what’s harmful for public health to finance crucial vaccines like rotavirus.

Learn more about opportunities for ear-marking funds for immunization, an approach also used in the Philippines and Costa Rica.

Was the vaccine well received by the public?

Rotavirus vaccine was very well received. Mothers and grandmothers in Mexico have seen several diseases disappear thanks to vaccines—first smallpox, then diphtheria, then wild poliovirus, and endemic measles. So, mothers and grandmothers love vaccines, and they trust doctors and nurses.

My mother used to tell me how she was the first one in line when the polio vaccine got into Mexico. One of her best friends had a child who had suffered polio and she didn’t want me to get it, so she was the first one in line.

How has the pandemic affected the provision of routine immunization for children?

During this pandemic, people have avoided going to health centers and hospitals because they don’t want to risk getting COVID disease. Coverage rates have declined, probably under 80%. The challenge now is to get children up to date on their shots by bringing the vaccines out of the medical units and into safe, open air public places.

What was the impact of rotavirus vaccine in Mexico?

I am proud that Mexico was the first country to publish evidence of the impact of rotavirus vaccine on infant mortality, with support from Manish Patel and Umesh Parashar at the CDC. Together we were able to prove in a couple of years, that there was a 41% reduction in gastroenteritis mortality in children <1, 29% in children 12-23 months, and an overall 35% reduction in children under 5. And the reductions have been progressive and sustained for at least 10 years. Especially during rotavirus season—see peaks on graph below—deaths have decreased 67% in children <5. This means saving at least 1,000 lives every year.

“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.”

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.

“You realize why so many babies with rotavirus actually don’t survive if they live far from a health care center. So many more lives can be saved with prevention measures like vaccination.”

Why was the decision to introduce rotavirus vaccines in South Africa so important?

South Africa was the first African country to introduce oral rotavirus vaccine in 2009. Having efficacy studies that were conducted in Africa was really pivotal to introducing rotavirus vaccine in South Africa and other African countries. For other vaccines, it has often proven difficult to introduce a vaccine when all available data were generated elsewhere. Together with PATH, we put out a lot of public messaging and policy briefs to disseminate what was the first real effectiveness data from Africa.

How was rotavirus vaccine accepted in South Africa?

Overall, I think South Africa has been quite accepting of vaccines. One particular challenge with rotavirus vaccines arises when someone’s child gets the vaccine and then gets diarrhea. The parent immediately thinks that the vaccine does not work, not understanding the vaccine’s role in preventing severe diarrheal disease and hospitalizations caused by rotavirus.

Were there any challenges when introducing rotavirus vaccines in South Africa?

One major challenge was that we had introduced pneumococcal conjugate vaccine, rotavirus vaccine, and switched to the pentavalent vaccine all at the same time. It was quite challenging to get the Expanded Programme on Immunization (EPI) staff up to speed on basically three new vaccines at once. It was logistically quite challenging and planning efforts such as education preparations could have used more attention.

Another challenge at the time was that, as a middle-income country, South Africa did not qualify for Gavi support, so the vaccine was a large additional cost to work into the budget. However, I think providing the data, having local clinical trials, and having very good advocates for rotavirus in South Africa who came before me, made the decision to introduce much easier.

The other remaining challenge in South Africa is that we have quite a disparate health system where richer provinces and urban areas tend to have better access to health care and very good vaccine coverage, while more rural and poorer provinces continue to still have relatively lower coverage. My eldest daughter was born in 2001 and wasn’t eligible for the rotavirus vaccine. She got infected when she was almost 9 months old. It was quite scary because she deteriorated in a couple hours. Fortunately, we were only 10 minutes away from a hospital, where she was admitted. You realize why so many babies with rotavirus actually don’t survive if they live far from a health care center. So many more lives can be saved with prevention measures like vaccination.

What efforts are being made to increase coverage to those that are hard to reach in South Africa?

We’ve actually never had a real challenge with vaccine hesitancy, but now the hesitancy with the COVID vaccines has filtered into other vaccines. Even for our combination parenteral/oral rotavirus study, we’ve had difficulty enrolling participants in our clinical trial. We have had to work towards addressing some of those vaccine fears.

In terms of reaching out to other areas, capacity is a recurring problem. But as more people become computer literate, getting information out in a virtual platform is really important. If we can educate, people can also be more vocal in asking for rotavirus vaccine and ensuring their children are protected. However, we have had a problem with access of resources to those poorer areas.

How has COVID impacted rotavirus vaccine coverage?

We had one of the strictest initial lockdowns when COVID was detected in South Africa in March last year, where we weren’t allowed out of our houses even to exercise. The problem with rotavirus vaccination is that we have the age restriction and cannot give it to children over 24 weeks. It’s possible that some children missed their vaccination appointments and slipped through the cracks. Unfortunately, it will again be the rural areas that will be the most affected.

However, several projects are planned and with things picking back up now, we are in the process of retrospectively looking at new rotavirus cases and diarrheal hospitalizations, and quantifying how much vaccination rates decreased while also monitoring for any resurgences in rotavirus. Due to the lockdown and increased social distancing there is less infection being spread, but these illnesses can come back if we reopen and children are not vaccinated.

What recommendations do you have for other countries who have yet to introduce rotavirus vaccine?

People forget that rotavirus isn’t just about the hospitalizations—there are parents who have to take time off work, along with other hidden costs from the burden of rotavirus. Pneumonia and diarrhea remain the major causes of death, disability, and lost years in young children. Having a first incidence of rotavirus or any diarrhea makes a child more prone to having repeat episodes, subsequent bacterial infections, and stunting. It’s a vicious cycle.

I always remember when we were doing the effectiveness study, the investigator from one of our rural sites phoned me worried that he wasn’t enrolling enough participants. The gastro wards were practically empty as a result of rotavirus vaccine use. Now, a new generation of doctors don’t know what it is like to have wards full of children with diarrhea. So even though we don’t have a perfect vaccine, it has made a huge impact in terms of saving lives.