Part 4 ROTA Council Advisors
The ROTA Council was created in collaboration with an advisory group of 24 child health leaders from around the world. Advisors continue to guide ROTA on scientific program and policy priorities.
A few of our advisors have shared their experiences in introducing rotavirus vaccines or maintaining high levels of coverage. In addition to strategies in advocacy and implementation, these interviews also aim to provide insights into how countries have dealt with the COVID-19 pandemic. By sharing various perspectives and ideas, we hope to create the sparks that lead to innovative strategies in minimizing the burden of rotavirus disease.
Dr. Mathuram Santosham was born in Vellore, India and obtained his MBBS degree from the Jawaharlal Institute of Post Graduate Medical Education and Research in Pondicherry, India in 1970. He subsequently moved to the US and obtained Board Certification in Pediatrics and an MPH degree from the Johns Hopkins University. He also completed a Fellowship in Pediatric Infectious Diseases at Johns Hopkins Hospital.
Dr. Santosham was the Founder and Director of the Johns Hopkins Center for American Indian Health (CAIH) from April 1991 to April 2016. He is currently the Director Emeritus of CAIH. He holds Professorships in the Departments of International Health and Pediatrics at Johns Hopkins University. He directed the Division of Health Systems for the Johns Hopkins Bloomberg School of Public Health from 2000-2009. He also serves as a Senior Advisor for the Johns Hopkins International Vaccine Access Center.
Dr. Santosham is internationally known for his work on oral rehydration therapy, childhood vaccines and dissemination of pediatric prophylactics to vulnerable populations worldwide. Working in partnership with Native American communities, he conducted landmark vaccine efficacy trials, including rotavirus vaccine, H. influenzae type b (Hib) conjugate vaccine, and pneumococcal conjugate vaccine. Native American children used to die from these diseases at rates 10 to 50 times the US average. Through his advocacy, these vaccines now save 3 to 5 million lives a year in the US and across the globe. In addition, Dr. Santosham worked with the White Mountain Apache Tribe to pioneer the use of oral rehydration solution (ORS), now known as “Pedialyte” in the US. Based on this evidence, ORS has become the standard of care for treating diarrheal dehydration, and is credited with saving 60 million lives since 1980. Dr. Santosham has become a global leader in the national and international dissemination of these public health strategies worldwide.
Dr. Santosham serves on numerous national and international committees to promote childhood health throughout the world. He consults for numerous international agencies including WHO, USAID, UNICEF and the Gates Foundation on aspects of child survival in over 30 countries. He is the author of over 270 peer-reviewed journals and serves as a reviewer for several international medical journals. He is the recipient of numerous awards including the Thrasher Research Fund Award for Excellence in Research (1988), Maurice Hilleman Lecturer at CDC (2008), and the Bob Austrian Orator, for International Symposium on Pneumococcas and Pneumococcal Disease (2006). He was also awarded the Indian Health Service Directors Award for Career Service in 2011, recognizing his personal dedication, commitment and contribution to the overall Indian Health Service Research Program and the global impact of his work. He received the Albert Sabin Gold Medal Award on April 29th, 2014. The Albert B. Sabin Gold Medal has been awarded annually since 1994 to a distinguished member of the research community who has made extraordinary contributions in the field of Vaccine sciences or a complementary field. On Oct 7th, 2014, he received the 2014 Fries Prize for Improving Health, “For his seminal research, vaccine development, policy, and advocacy toward the global prevention of Haemophilus influenza type b (Hib) disease saving each year more than 370,000 children’s lives.
Umesh Parashar leads the CDC Division of Viral Diseases Enteric Viruses Epidemiology Team. He is the co-lead of the Advisory Committee on Immunization Practices Working Group, which developed recommendations for rotavirus vaccine use in the US.
Dr. Parashar and the CDC Enteric Viruses Team were responsible for disease burden and surveillance activities for the Rotavirus Vaccine Program (RVP) a partnership between the CDC, WHO and PATH, supported by GAVI. From 2003-2009, RVP worked to accelerate the introduction of rotavirus vaccines in developing countries with the greatest rotavirus disease burdens.
Dr. Parashar has spent more than 15 years at the CDC researching the epidemiology of viral gastroenteritis and methods for its prevention and control. His research has included the development of rotavirus vaccination strategies. Dr. Parashar first joined the CDC as an epidemic intelligence service officer in 1996.
He has published more than 170 scientific papers and book chapters and has given numerous presentations at scientific conferences. He also served as a guest editor of four supplements for leading scientific journals and on WHO advisory committees.
Dr. Parashar attended medical school in India and completed his postgraduate training in public health and preventative medicine in the United States. He holds an MD and MBBS.
Deborah Atherly, PhD, BScPharm, is Director, Health Economics and Outcomes Research at PATH. Dr. Atherly is responsible for conducting economic and financial evaluations on drugs, vaccines and diagnostics targeted for use in developing countries. In this role, she has developed global demand and supply forecasts for vaccines, including rotavirus and human papilloma virus (HPV) and has evaluated the health and economic impact of vaccines on developing country populations.
She has conducted market assessments, including in-depth analyses of the actual or expected costs of manufacturing (COGS) and expected revenues for vaccines in development, including rotavirus, pneumococcal, HPV, MenA, ETEC and Shigella. Dr. Atherly has worked in many sub-Saharan African countries to collect and evaluate economic data in order to strengthen evidence for decisions on vaccine introduction. She also assists ministries of health with the interpretation and communication of these data. She has worked extensively in partnership and advisory roles with many global health agencies including Gavi, the Vaccine Alliance; UNICEF; WHO; PAHO and the Bill & Melinda Gates Foundation.
Prior to joining PATH, Dr. Atherly worked in both the private and public sectors. While at Parke-Davis, Johnson & Johnson, and as a consultant to other pharmaceutical companies, she developed and conducted economic and financial analyses, including cost-effectiveness, return on investment and demand forecasting. Based on these analyses, she implemented strategic plans for communication of these data to policymakers. She was a pharmacy director, and has held various clinical leadership positions in hospitals and health systems. Dr. Atherly is a pharmacist and received her PhD in Pharmacoeconomics and Outcomes Research from the University of Washington.
Dr. Ciro A. de Quadros was the Executive Vice President of the Sabin Vaccine Institute. Before joining Sabin in 2003 he was Director of the Division of Vaccines and Immunization of the Pan American Health Organization in Washington, DC. He directed the successful efforts of polio and measles eradication from the Western Hemisphere.
Dr. de Quadros was involved with the pioneering experiences for the development of the strategies of surveillance and containment for Smallpox eradication and joined the World Health Organization in 1970 where he held the position of Chief Epidemiologist for the Smallpox Eradication Program in Ethiopia. In January 1977 he was transferred to PAHO to serve as the Regional Advisor for implementation of the Expanded Program on Immunization in the Region of the Americas.
Between 1994 and 2000 he served as Special Adviser to the WHO Director General on matters related to the implementation of the Global Program for Vaccines (GPV), representing WHO in the Children’s Vaccine Initiative (CVI) Governing Bodies. This assignment was taken in conjunction with the position of Director of Special Program for Vaccines and Immunization at the Pan American Health Organization, where he advised Member governments in all matters related to vaccines and immunization, including issues related to vaccine research and development, production, quality control, vaccine licensing and introduction into national immunization programs. It also included the planning and implementation of programs aimed at the control and/or eradication of vaccine preventable diseases, including the organization of surveillance systems and laboratory support for diagnostics.
Dr. de Quadros was also the chairperson of the Technical Advisory Group (TAG) on Vaccines and Immunizations of the Pan American Health Organization and an Associate Adjunct Professor at the Johns Hopkins Bloomberg School of Public Health and an Adjunct Professor in the Department of Tropical Medicine of the School of Medicine of George Washington University in Washington DC.
Dr. de Quadros published over 100 papers, chapters and articles and participated and presented lectures in over 100 conferences throughout the world. He received several international awards, including the 1993 Prince Mahidol Award of Thailand, the 2000 Albert B. Sabin Gold Medal, the 2004 “Orden Civil de la Sanidad” given by the Government of Spain, and the PAHO Public Health Hero of the Americas award in 2014. In 1999 he received the highest civil award given by the Government of Brazil, the Order of Rio Branco. And in 2010, he received the Premio Carlos IV Award for Research in Preventive Medicine and Public Health from Spain’s Royal National Academy of Medicine (RANM). He was also a member of the Institute of Medicine of the National Academies of the USA.
He completed his medical studies in Brazil in 1966 and received a Master of Public Health degree from the National School of Public Health in Rio de Janeiro in 1968.
George Armah is a senior research fellow and an associate professor in the Department of Electron Microscopy and Histopathology at the Noguchi Memorial Institute for Medical Research at the University of Ghana. He is head of the West African Regional Rotavirus Reference Laboratory, which provides technical support, resources and training for rotavirus surveillance in Africa.
Professor Armah has spent nearly two decades working on rotavirus in Africa and is an active member of the African Rotavirus Network, which conducts hospital-based surveillance of rotavirus in children under five using standardized WHO protocol. His research focuses on enteric diseases and specifically, the epidemiology of rotavirus and norovirus in Africa and their genetic and antigenic characterizations.
Professor Armah is also a senior clinical trials program lecturer at the University of Ghana School of Public Health. He has participated in several clinical trials including Merck’s RotaTeq rotavirus vaccine efficacy trial in Africa, where he served as one of the principal investigators.
Professor Armah is a member of Vaccines for Africa, a group of African vaccinologists, scientists and public health advocates working to accelerate the introduction of lifesaving childhood vaccines within the region and to promote equity in access to these vaccines.
Professor Armah obtained his PhD in biophysical chemistry and immunology from the Faculty of Pharmaceutical Sciences of Osaka University in Japan in 1990.
“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.
Mamadou Ba is head of the Emergency and Pneumology unit at Albert Royer Children’s Hospital in Dakar, Senegal.
Dr. Ba participated in drafting Senegal’s application for GAVI support which, when approved in 2004, enabled Senegal to introduce both Haemophilus influenzae type b (Hib) conjugate and hepatitis B vaccines into Senegal’s Expanded Program of Immunization. Following this, statistics showed a major decrease in the child death rate, suggesting that with better and higher immunization coverage, a direct and long-term positive impact on infant and child mortality could be achieved.
He began his work at Albert Royer Children’s Hospital in 2002 as the sentinel site’s supervisor. This hospital was selected by the World Health Organization as the sentinel site for the network surveillance of rotavirus diarrhea, pediatric bacterial meningitis, Hib, Streptococcus pneumonia and Nesseiria meningitidis.
Dr. Ba graduated from University Cheikh Anta Diop in Dakar (UCAD) in 1980. From 1985 to 1987 he studied pediatric pneumology as a resident and fellow at Montreal Sainte Justine Hospital, the Children’s Hospital at the University of Montreal in Canada. In 1987, he was awarded a prize for continuous medical training research. Dr. Ba became an assistant professor of pediatrics at the African and Malagasy Council for Higher Education (CAMES) in 1992. In 1996, he was appointed senior professor of pediatrics at UCAD. While at UCAD, Dr. Ba published over 200 original medical and scientific articles.
In 2001, Dr. Ba was nominated for the Knight of the Senegalese National Order of the Lion, one of the most prestigious awards given by the Republic of Senegal. In 2010, he awarded a diploma of ADVAC (Advanced Course of Vaccinology), a two week training program for decision makers on vaccines and vaccination.
He is a member of several international scientific boards, including the West African Rotavirus Advisory Board.
Julie Bines is the inaugural Victor and Loti Smorgon Chair of Paediatrics at the University of Melbourne. She is a paediatric gastroenterologist and head of clinical nutrition at the Royal Children’s Hospital in Melbourne, Australia. Dr. Bines also heads the Rotavirus Vaccine Program for RV3, a new rotavirus vaccine candidate, at the Murdoch Children’s Research Institute. The program is working to develop a low-cost neonatal rotavirus vaccine which would prevent the virus from birth.
Throughout her career, Dr. Bines has focused on rotavirus vaccine safety. She was involved in the development and validation of the Brighton Collaboration clinical case definition of intussusception, WHO documents outlining the epidemiology of intussusception in developing countries, and generic protocols for intussusception and post-marketing surveillance following rotavirus vaccine introduction.
In 2004, Dr. Bines was awarded the Australian National Health and Medical Research Council Practitioner Fellowship and in 1990, she was awarded the Royal Australasian College of Physicians Fellowship.
She received a MBBS from Monash University in Melbourne, Australia in 1982. She received her MD from the University of Melbourne 2000.
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.
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.
Lulu Bravo is Professor of Pediatric Infectious and Tropical Diseases at the College of Medicine, University of the Philippines Manila. She is the former Vice Chancellor for Research and Executive Director of the National Institutes of Health, University of the Philippines Manila.
She has served as World Health Organization (WHO) temporary adviser and member of the WHO Technical Steering Committee of the Child and Adolescent Health Department raising awareness on the Control of Diarrheal Disease program (CDD) since 1985, followed by the WHO Integrated Management of Childhood Illness (ICMI) in recent years. She has organized and conducted hundreds of training seminars for pre-service and in-service on the WHO Case management for Diarrheal Diseases as well as on the IMCI. She has conducted clinical trials on oral rehydration solution (ORS) in the 1990s and vaccine trials in the last 15 years, and has published more than 75 papers and abstracts, locally and internationally, on various infectious diseases topics.
At present, she is President of the Immunization Partners in Asia Pacific (IPAP) and current Executive Director and immediate past President of the International Society of Tropical Pediatrics, past Chair of the Asian Strategic Alliance for Pneumococcal Disease Prevention (ASAP), and former president of the Asian Society for Pediatric Infectious Disease (ASPID).She has served in various capacities in many other Asian medical and professional societies as well as in Philippine health associations including the Philippine Foundation for Vaccination (PFV) of which she is the founding President. She is also a member of the Pneumococcal Awareness Council of Experts (PACE) and member of the TWG of the Dengue Vaccine Initiative (DVI). Her work has earned for her various honors and awards in the academic and research fields, including the Dr. Jose P. Rizal Memorial Award for Academe and the 2012 Asian Outstanding Pediatrician Award given by the Asia Pacific Pediatric Association.
Dr. Lulu Bravo completed her MD, pediatric residency and subspecialty training in infectious disease at Philippine General Hospital-College of Medicine of the University of the Philippines Manila. She completed her fellowship in paediatric infectious disease at the University of Texas Southwestern Health Science Center in Dallas, USA in 1986.
“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.
Nigel Cunliffe is a professor of medical microbiology and head of the Department of Clinical Infection, Microbiology and Immunology at the Institute of Infection and Global Health, University of Liverpool. Dr. Cunliffe has investigated rotavirus infections in children since 1996, when he spent a year as visiting Fellow in the Viral Gastroenteritis Section at the Centers for Disease Control and Prevention (CDC) in Atlanta, Georgia.
Dr. Cunliffe has principally focussed his research efforts addressing the epidemiology and prevention of rotavirus gastroenteritis in children in Malawi. He led a pivotal clinical trial in Malawi that demonstrated the efficacy of the monovalent human rotavirus vaccine in preventing severe rotavirus gastroenteritis, which informed WHO’s global rotavirus vaccine recommendation. He has recently led a research program in Malawi that has demonstrated the real-world clinical and cost effectiveness of rotavirus vaccine following its introduction into Malawi’s immunisation programme in 2012.
Currently, Dr. Cunliffe is assessing the impact of routine rotavirus vaccination in Merseyside, UK. He has published over 100 scientific papers, predominantly on rotavirus. Dr. Cunliffe obtained his medical degree from the University of Manchester in 1988 and his PhD from the University of Liverpool in 2001.
Shams El Arifeen is a senior scientist and director of the Centre for Child and Adolescent Health at ICDDR,B. Dr. Arifeen currently heads the Child Health Unit at ICDDR,B where he works extensively on child and neonatal health, health services and health systems research. Dr. Arifeen is also an adjunct professor at the James P. Grant School of Public Health at the BRAC University in Bangladesh, where he teaches epidemiology and supervises MPH students in their independent research.
Dr. Arifeen has nearly 25 years of experience in child health, including nine years in government health services, with a focus on health interventions for developing populations. He also has extensive experience in research design and implementation, with particular expertise in cluster randomized trials and large-scale surveys as well as with community and facility-based evaluations of interventions and programs, using both experimental and quasi-experimental designs.
He actively participates in national efforts within Bangladesh to scale up the evidence base on neonatal and child health interventions. Dr. Arifeen currently leads the team assisting the government of Bangladesh and its partners in monitoring and evaluating health services and programs.
He provides technical assistance to the government of Bangladesh, nongovernmental organizations and other organizations. He has served on a number of Bangladesh’s technical and advisory committees, including the National Committee on Immunization Practices, Technical Sub-Committee on National Newborn Health Strategy and the Bangladesh Demographic and Health Survey, Urban Health Survey and Bangladesh Maternal Mortality Survey technical committees.
Dr. Arifeen contributed to the 2003 Lancet Series on Child Survival and has published more than 135 scientific articles in peer-reviewed journals.
Dr. Arifeen holds an MBBS and PhD and has trained in medicine, public health, nutrition and epidemiology.
Carlo Giaquinto is a paediatrician and head of the Referral Centre for Paediatric HIV infection in the Department of Paediatrics at the University of Padova. He is an honorary senior lecturer at the Centre for Paediatric Epidemiology and Biostatistics in the Institute of Child Health in London, England.
A leading expert in paediatric rotavirus infection and vaccination, Dr. Giaquinto is the primary investigator of the REVEAL study, which examines the age distribution of rotavirus gastroenteritis cases in European children. He is a member of the European Centre for Disease Prevention’s working group for rotavirus vaccination and a member of the European Paediatric Vaccine Advisory Board.
He chairs the Paediatric European Network for the Treatment of AIDS (PENTA) Steering Committee, and is vice president of Fondazione Moschino, which serves as a coordinating body for associations working with HIV-affected children and families. Dr. Giaquinto also chairs the Fondazione Cassa di Risparmio di Ascoli Piceno, which supports the promotion of local economic development.
Dr. Giaquinto is the coordinator of several international research projects focused on his primary interest, the field of childhood infectious diseases. He was a member of the Italian Ministry of Health’s national committee for the fight against infectious diseases and a member of Comite Restreint del Fonds de Solidaritè Terapeutique International, which provides grants for research on the prevention and treatment of diseases.
Dr. Giaquinto reviews several international scientific journals including The Lancet, Pediatric Infectious Disease Journal and Paediatrics and is a member of the editorial board for the Journal of Infectious Diseases.He is the author or co-author of more than 190 articles published in peer-reviewed journals. Dr. Giaquinto has been invited to speak at more than 400 conferences and international workshops across the world.
He graduated with a MD in 1982 and specialized in pediatrics in 1986 from the University of Padova in Italy.
Roger I. Glass, MD, PhD, was named Director of the Fogarty International Center and Associate Director for International Research by NIH Director Elias A. Zerhouni, MD, on March 31, 2006.
Dr. Glass graduated from Harvard College in 1967, received a Fulbright Fellowship to study at the University of Buenos Aires in 1967, and received his M.D. from Harvard Medical School and his M.P.H. from the Harvard School of Public Health in 1972. He joined the Centers for Disease Control and Prevention in 1977 as a medical officer assigned to the Environmental Hazards Branch. He was a Scientist at the International Center for Diarrheal Disease Research in Bangladesh from 1979-1983 and returned to Sweden where he received his doctorate from the University of Goteborg. In 1984, he joined the National Institutes of Health Laboratory of Infectious Diseases, where he worked on the molecular biology of rotavirus. In 1986, Dr. Glass returned to the CDC to become Chief of the Viral Gastroenteritis Unit at the National Center for Infectious Diseases.
Dr. Glass’s research interests are in the prevention of gastroenteritis from rotaviruses and noroviruses through the application of novel scientific research. He has maintained field studies in India, Bangladesh, Brazil, Mexico, Israel, Russia, Vietnam, China and elsewhere. His research has been targeted toward epidemiologic studies to anticipate the introduction of rotavirus vaccines. He is fluent and often lectures in five languages.
Dr. Glass has received numerous awards including the prestigious Charles C. Shepard Lifetime Scientific Achievement Award presented by the CDC in recognition of his 30-year career of scientific research application and leadership, and the Dr. Charles Merieux Award from the National Foundation for Infectious Diseases for his work on rotavirus vaccines in the developing world. Dr. Glass is also the recipient of the 2015 Albert B. Sabin Gold Medal Award. He is a member of the Institute of Medicine of the U.S. National Academy of Medicine. Dr. Glass has co-authored more than 600 research papers and chapters.
He is married to Barbara Stoll, MD, the H. Wayne Hightower Distinguished Professor in the Medical Sciences and Dean of the University of the Texas Medical School at Houston, and the father of three children: Nina, Michael and Andy Glass.
Zulkifli Ismail is a consultant paediatrician and paediatric cardiologist in a private hospital. He also serves as a visiting paediatric cardiologist at Damansara Specialist Hospital. He was formerly a professor of paediatrics and paediatric cardiology in Universiti Kebangsaan Malaysia(UKM). He has served as the head of the paediatric department and the director of Hospital Universiti Kebangsaan Malaysia (HUKM) as well as the medical director of its private wing, UKM Specialist Centre.
Dr. Zulkifli also served as a past president of the Malaysian Paediatric Association (MPA) and is currently the editor of Berita MPA, a quarterly newsletter publication distributed to fellow members of the Association. He is also the chairman of the Positive Parenting Management Committee and serves as the chief editor of the Positive Parenting Guide, a quarterly publication aimed to equip Malaysian parents with reliable and practical local information on maternal, child and family care since 2002. Dr. Zulkifli is currently the president-elect of the Asia Pacific Pediatric Association (APPA) and current chairman of the Asian Strategic Alliance for Pneumococcal disease prevention (ASAP). He is also president of the Thalassaemia Association of Malaysia (TAM) from 2003. He serves as a board member of the National Population and Family Development Board (LPPKN), is a member of the Ministry of Health Unrelated Transplant Approval Committee (UTAC) and in the editorial board of the Malaysian Journal of Paediatrics & Child Health (MJPCH). He has also served as a reviewer for the Medical Journal of Malaysia and the Philippines Pediatric Infectious Disease Journal.
He has more than 35 publications in peer-reviewed international and local journals in addition to numerous abstracts and articles for the lay-public on various issues involving child health, paediatrics and vaccinology. He has authored or co-authored two books for parents, one for medical students and one for nurses. In 2008 he was conferred the Darjah Panglima Mahkota Wilayah by the Malaysian King that carries the honorific title of ‘Datuk’.
Dr. Zulkifli received his MBBS from University of Malaya in 1981, Master of Medicine (MMed) in Paediatrics in 1989 and was a fellow of the Academy of Medicine of Malaysia (FAMM) in 1999 and of the Royal College of Paediatrics and Child Health in the UK in 2007.
Gagandeep Kang is a professor in the Department of Gastrointestinal Sciences at the Christian Medical College (CMC) in Vellore, India. She is vice principal of research, deputy chairperson of the Institutional Review Board and head of the Wellcome Trust Research Laboratory at CMC.
Dr. Kang’s research focuses on enteric infections in children. She recently studied hospital and community-based surveillance utilizing new molecular procedures to investigate immune responses in children with viral and parasitic enteric infections. She has worked to determine modes of transmission and assess immune responses to design effective interventions for addressing enteric infections in children. She has also served as an investigator on national and internationally funded diarrheal disease research grants.
In 2006, Dr. Kang received the Indian National Award for Women Bioscientists for her significant contributions to the understanding of the molecular epidemiology of rotavirus in children.
In 1999, she served as a visiting fellow at the Baylor College of Medicine in Houston, Texas, and in 1998, she was a visiting fellow at the Health Protection Agency in London, England. Dr. Kang worked as a lecturer and a reader in the Department of Gastrointestinal Sciences at CMC from 1991 to 1998.
Dr. Kang has published numerous papers in national and international journals. She is the recipient of India’s National Talent Scholarship and has been honored with a core research professorship and Lourdu Yedanapalli Research Award by CMC.
Dr. Kang received international, honorary appointments as an associate faculty member at the Johns Hopkins University Bloomberg School of Public Health in Baltimore, Maryland, and adjunct professor at Tufts University School of Medicine in Boston, Massachusetts.
She received her MD in clinical microbiology in 1991 and her PhD in microbiology in 1998 from CMC in India.
Li Li, MD, MPH, was born and raised in Shandong, China. After graduating from Shandong Medical University in 1987, he joined the EPI program in Shandong provincial hygiene and prevention station, gaining foundational experience from field work. In 1991, he attended a poliomyelitis control project in China, supported by the Japan International Cooperation Agency (JICA), and received the Monbushu Scholarship to pursue a master’s and doctorate degree in Japan from 1999-2005.
In April 2005, he became an epidemiologist in the National Immunization Program (NIP), Chinese Center for Disease Control and Prevention (CDC). Dr. Li was appointed as director of NIP in May 2012. Since December 2014, he has been serving as the deputy secretary-general of CPMA.
Dr. Li’s research efforts focus on surveillance of vaccine-preventable diseases and evidence-based recommendations for immunization in China. He has a strong background in EPI field work and international cooperation. As a professor of epidemiology, he mentors postgraduate students. He is also an executive editorial board member and managing director of the Chinese Journal of Vaccines and Immunization. Dr. Li is a member of the National Advisory Committee on Adverse Events Identification Following Immunization in China and a member of Governing Council of the International Association of Immunization Managers (IAIM).
During 2007-2008, Dr. Li served as vice secretary general to Aba prefectural government in Sichuan province. He received the honor of “National Model of Earthquake Disaster Relief” given by the Chinese central government in 2008.
Dr. Li received his Bachelor of Public Health from Shandong Medical University in China in 1987, and his MSc and PhD of health science from The University of Tokyo in Japan in 2002 and 2005. He was a guest researcher at the U.S. Centers for Disease Control and Prevention in 2013.
Alexandre Linhares is head of the Virology Section of Instituto Evandro Chagas, which works with the Secretariat of Health Surveillance at the Brazilian Ministry of Health. Dr. Linhares has been a professor of virology at the Federal and State Universities of Pará in Brazil. He has also been the scientific editor of the Pan-Amazonian Journal of Health since its launch in 2010.
Dr. Linhares is credited with first detecting rotavirus in Brazil in 1976. Since then he has been actively involved in researching viral infections in humans in the Amazon region of Brazil, with particular emphasis on the viral gastroenteritis and rotavirus vaccines.
He is a honorary member of the Brazilian National Academy of Military Medicine and a member of the Brazilian Society for Infectious Diseases, Brazilian Society of Tropical Medicine and the Brazilian Society for Virology.
Dr. Linhares received his MD in 1975 from the Federal University of Pará State in Brazil and received his PhD from Fundação Oswaldo Cruz in Rio de Janeiro in 2002. Dr. Linhares’s publications include a “Health in the Amazon” textbook, several book chapters and more than 120 articles in peer-reviewed scientific journals; he also acts as a reviewer for several Brazilian and international scientific journals. Dr. Linhares has given several lectures at national and international scientific conferences.
“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.
Erkin Musabaev is the director of the institute of virology at the Ministry of Health in Uzbekistan. He is also a senior infectionist at the Public Health Service of Uzbekistan, head of the infectious diseases department at the Tashkent Institute of Advanced Medical Studies and the director of the National Reference Laboratory in Uzbekistan.
Previously, Dr. Musabaev was the director of the Tashkent City Fever Hospital. He was a researcher in epidemiology and deputy director on sciences at the Microbiology and Infectious Diseases Research Institute.
He received his PhD in 1983 and his MD in 1990 from the Epidemiology Research Institute of the Ministry of Health of USSR. He studied at the Tashkent State Medical Institute from 1973 to 1979 and then participated in advanced clinical studies and a post graduate course in epidemiology at the Microbiology and Infectious Disease Research Institute.
Tony Nelson is a professor in paediatrics at the Chinese University of Hong Kong. Over the course of his career, he has worked in Hong Kong, Malawi, New Zealand, Saudi Arabia, Zimbabwe and South Africa.
His research interests include vaccines and disease surveillance, infant and child nutrition, and sudden infant death syndrome. He is a member of the SAGE Working Group on maternal and neonatal tetanus elimination and broader tetanus control and Hong Kong’s Scientific Committee on Enteric Infections and Food Borne Diseases. He has been a member of the WHO Expert Advisory Group on Quantitative Immunization and Vaccines Related Research (2007-2012) and a technical advisor for the Supporting Independent Immunization and Vaccine Advisory Committees Initiative (2008-2011).
Dr. Nelson served as a paediatric specialist at Kamuzu Central Hospital in Malawi from 1989 to 1993. He was a paediatric registrar at Dunedin Public Hospital, New Zealand in 1985 and at the Riyadh Military Hospital, Saudi Arabia in 1982 to 1983.
Dr. Nelson co-edited journal supplements for the Asian Rotavirus Surveillance Network (ARSN) in 2005 and 2009, and for the Supporting Independent Immunization Vaccine Advisory Committees in 2010. From 2000 to 2003, he coordinated rotavirus surveillance at four Hong Kong hospitals for ARSN.
As the director of CVD, Dr. Neuzil leads an academic vaccine research and development enterprise that is engaged in the full range of vaccinology—from basic laboratory science research through vaccine development, early clinical evaluation, large-scale pre-licensure field studies and post-licensure assessments. Dr. Neuzil’s own research career has focused on epidemiology and clinical trials for vaccine-preventable diseases, with an emphasis on viral pathogens including influenza, RSV and rotavirus.
Before joining the University of Maryland in 2015, Dr. Neuzil held an academic appointment at the University of Washington School of Medicine directed PATH’s activities in vaccine access and delivery, which focus on developing and advancing strategies, technologies and interventions that help move research achievements in immunization into routine use in the field. Dr. Neuzil provided strategic leadership, direction and technical guidance for a variety of vaccine projects and studies, including work on vaccines against rotavirus, HPV, Japanese encephalitis and influenza.
Dr. Neuzil has extensive experience in domestic and international policy, including membership on the Centers for Disease Control Advisory Committee on Immunization Practices and the Pandemic Influenza Task Force for the Infectious Disease Society of America. Dr. Neuzil has worked with the World Health Organization as a technical advisor on diarrheal diseases, member of the Strategic Advisory Group of Experts rotavirus vaccine working group, and member of the Global Advisory Committee on Vaccine Safety working group on the safety of vaccines in pregnancy.
She has contributed more than 160 scientific papers on vaccines and infectious diseases. She is currently an Associate Editor of the journal Vaccine and on the editorial board of npj Vaccines.
Dr. Neuzil received her BS in zoology from the University of Maryland, her MD from Johns Hopkins University School of Medicine and her MPH from Vanderbilt University. She received her training in internal medicine and infectious diseases at Vanderbilt University.
Vesta Richardson is a pediatrician and the Minister of Health for the State of Morelos in Mexico. Previously, she served as general director of the National Center for Child and Adolescent Health in the Mexican Ministry of Health, which works to decrease infant mortality through Mexico’s Immunization Program and the National Immunization Council.
Dr. Richardson has conducted seminal research on rotavirus vaccines. She co-authored a study on the impact of rotavirus vaccination on diarrhea mortality in Mexican children and in a separate study, examined the risk of intussusceptions risk and health benefits of the rotavirus vaccination in Mexico and Brazil.
From 2004 to 2007, Dr. Richardson was medical director of the Hospital Infantil de México Federico Gómez. In 2003, she founded the Clínica Londres Cuernavaca and in 1995, she founded and directed the Hospital del Niño Morelense in the city of Cuernavaca, Mexico.
Dr. Richardson was the director of the University of Baja California Pediatric Residency Program for six years. She also served as co-director of the Boston University Residency Program for three years and as the director of the University of Morelos Pediatric Residency Program for seven years.
She has published more than 40 scientific papers in specialized journals and books. Dr. Richardson has given dozens of lectures, coordinated several panel discussions and has been invited as a consultant and member of numerous evaluation committees.
Dr. Richardson earned her MD at La Salle University Medical School in Philadelphia, Pennsylvania in 1980. Her medical experience and pediatric skills were acquired at the Hospital Infantil de México and the Hospital General de México. She completed her pediatric residency at Boston City Hospital and Massachusetts General Hospital in Boston, Massachusetts.
“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.
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.
Duncan Steele, PhD, is a microbiologist with extensive experience in virology and microbiology, especially for diarrheal diseases and in clinical trials. Before starting at the foundation as a Senior Program Officer in October 2011, Duncan was the Senior Technical Advisor at PATH on enteric vaccines for PATH’s Vaccines and Immunization Program. Dr. Steele worked directly with the Advancing Rotavirus Vaccine Program, which develops affordable, alternative live attenuated rotavirus vaccines with developing country manufactures in India, Brazil and China. He also worked with the Enteric Vaccines Initiative, which develops vaccines against enterotoxigenic E coli and Shigella spp. for young children in developing countries. Dr. Steele has over three decades of experience in diarrheal disease control.
Dr. Steele fulfilled a key role in the unprecedented Merck and GlaxoSmithKline rotavirus vaccines clinical studies conducted in developing countries in Africa and Asia. These studies informed the WHO’s recommendation for the global use of rotavirus vaccine.
Prior to joining PATH, Dr. Steele served as a scientific officer at the WHO’s Initiative for Vaccine Research. He was responsible for diarrhea and enteric vaccine development and coordinated the global strategic research agenda on major diarrhea and enteric disease vaccines, including rotavirus, cholera, ETEC, Shigella and typhoid fever.
Earlier in his career, Dr. Steele conducted clinical microbiology/virology laboratory research in South Africa and served as co-director of the Medunsa Medical Research Council’s Diarrhoeal Pathogens Research Unit based at the University of Limpopo, South Africa, which studied viral and microbial agents associated with diarrhea in young children in Southern Africa.
Dr. Steele graduated from the University of Cape Town in South Africa with a Bachelor of Science (BS) in microbiology in 1979. He received his PhD in microbiology and virology from the University of Limpopo, South Africa in 1990.
- Risk of Intussusception Following Administration of a Pentavalent Rotavirus Vaccine in US Infants – Journal of the American Medical Association, February, 2012
- Parashar UD, Tate J, Johnson H, Steele AD. Health impact of rotavirus vaccination in developing countries – Progress and a way forward. Clin Infect Dis 2016 May; Suppl 2: S91-95
- Zaman K, Fleming JA, Victor JC, Yunus M, Bari TIA, Azim T, Rahman M, Mowla SMN, Bellini WJ, McNeal M, Icenogle JP, Lopman B, Parashar U, Cortese MM, Steele AD, Neuzil KM. Human rotavirus vaccine can be safely administered at 9 months of age with Measles-Rubella vaccine boosting the rotavirus immune response status of Bangladeshi infants. J Infect Dis 2016; Jan 27. pii: jiw024
- Armah GE, Lewis K, Cortese M, Parashar U, Ansah A, Gazley L, Victor JC, McNeal MM, Binka FN, Steele AD. A randomized controlled trial of the impact of alternative dosing schedules on the immune response to human rotavirus vaccine in rural Ghanaian infants. J Infect Dis 2016; Jan 27. pii: jiw023
Oyewale Tomori is a professor of virology at Redeemer’s University, Nigeria. He has wide-ranging experience in virology, disease prevention and control, national capacity building and development in the African region. Dr. Tomori holds fellowships from the Nigerian Academy of Science, Nigerian College of Veterinary Surgeons and the United Kingdom’s Royal College of Pathologists.
From 1994-2004, Dr. Tomori served as the WHO’s African region laboratory coordinator and advisor on laboratory development and virus control. At the WHO, Dr. Tomori established the Africa Regional Laboratory Network for the diagnosis of polio and other viral diseases. He also provided counsel and assistance to countries in the region in establishing, managing and monitoring laboratory services and ensuring the use of laboratory data in instituting disease preventive and control measures.
In 2002, Dr. Tomori received the Nigerian National Order of Merit, the country’s highest award for academic and intellectual attainment and national development. In 1981, he was recognized by the United States CDC for his contribution to Lassa fever research.
Dr. Tomori also serves on several advisory bodies including the WHO Polio Research Committee, WHO Africa Regional Polio Certification Committee, WHO Eastern Mediterranean Regional Polio Certification Committee, WHO Advisory Committee on Variola Virus Research, WHO Group of Experts on Yellow Fever Disease, the board of BioVaccines Limited in Nigeria and the International Steering Committee of the International Consortium on Anti-Virals (ICAV) in Canada. ICAV is a nonprofit drug development organization that works to discover and develop anti-viral therapies for neglected and emerging diseases.
His research includes a wide range of human and zoonotic viruses.
Dr. Tomori received his Doctor of Veterinary Medicine (DVM) from the Ahmadu Bello University in 1971 and a PhD in virology from the University of Ibadan in 1976. Both universities are located in Nigeria.
K. Zaman, MBBS, PhD, MPH, is senior scientist and epidemiologist at the International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b).
For the last 33 years, Dr. Zaman has worked extensively in the design, implementation and analysis of data from clinical and community-based epidemiological/vaccine studies. His research primarily focuses on vaccines and infectious diseases. He has been involved with clinical studies on ORS, drug trial, vaccine studies, vitamin A supplementation and hospital surveillance. Dr. Zaman also has experience in community-based research on diarrheal and respiratory diseases, as well as other public health problems in Bangladesh.
Currently he is the Principal Investigator leading several rotavirus, influenza, pneumococcal, Hepatitis E, polio and Japanese encephalitis (JE) vaccine studies as well as epidemiological studies on tuberculosis in icddr,b. The vaccine studies included all of phases I, II, III, IV and with International Conference on Harmonisation Good Clinical Practice maintained.
Dr. Zaman obtained his MBBS in Bangladesh; he obtained his MPH and PhD from the Johns Hopkins University in infectious disease control. He has 145 publications in international journals and more than 120 presentations in scientific conferences. Dr. Zaman also serves as Section Editor of the Journal of “Health, Population and Nutrition” and is a reviewer for more than 20 international journals.
Fred Were is a professor of Perinatal and Newborn Medicine, dean of the School of Medicine at the University of Nairobi (UON), and chief executive officer of Kenya Paediatric Research Consortium. He graduated with a medical degree from the UON in 1984. He then undertook pediatric residency at the Kenyatta National Hospital, the teaching facility of the UON and graduated as a pediatrician in 1990. He obtained a fellowship in perinatal/neonatal medicine from the Monash University/Medical Centre in 1993. He was appointed lecturer in the UON in 1994 and obtained his PhD at the UON in 2007.
Prof. Were’s research interests lie in the areas of newborn medicine (with particular emphasis on nutrition of low birth weight infants) and health systems. He is committed to promoting child health advocacy, displaying particular vigor in the area of increasing childhood immunization coverage and public awareness. He has generated over 130 publications from his research activities.
Prof. Were previously served as national chairman of the Kenya Paediatric Association (2002-2012), committee member of the World Association of Perinatal Medicine (2008-2011), member of the International Pediatric Association Standing Committee (2013-2016), and president of the International Society of Tropical Paediatrics (2014-2017). He currently serves as chairman of the Network for Education and Support in Immunizations (from 2014), president of the Eastern African Paediatric Association (from 2010), and member of the Global Rotavirus Academy.
In addition, Prof. Were has sat on many immunization related committees, including the WHO African Technical Advisory Group for Measles (2013-2016) and the WHO African Technical Advisory Group for Immunization (2012-2015). He is currently a member of the WHO Strategic Advisory Group of Experts on Immunization (SAGE) (from 2013). Locally, he is chair of the National Immunization Technical Advisory Group (NITAG) (from 2014), the National Polio Certification Committee (from 2013), and the National Immunization Coordinating Committee (from 2017). Prof. Were has also participated in many advocacy groups including the African Vaccines & Immunization Network and the Pneumococcal Awareness Council of Experts.
“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.