Afghanistan had a high estimated rotavirus mortality rate (98 per 100,000) and among the world’s highest number of annual rotavirus-related deaths, totaling about 4,800.Tate, J.E., et al., Global, Regional, and National Estimates of Rotavirus Mortality in Children <5 Years of Age, 2000–2013. Clinical Infectious Diseases, 2016. 62(suppl 2): p. S96–S105. Given the substantial burden of disease and the Ministry of Public Health’s priority to reduce child mortality by one-third by 2020 (from the 2003 level), the country successfully applied for Gavi support in 2017 and introduced the vaccine in 2018.

First discovered there more than 40 years ago, Australia and rotavirus have a long history together—the country’s scientific minds have played a critical role in improving child health and combatting global rotavirus illnesses and deaths. Australian virologist Dr. Ruth Bishop and her team of researchers at the Royal Children’s Hospital in Melbourne identified the virus in 1973, setting the stage for the development of the vaccines that have saved hundreds of thousands of lives over the last decade.Global vaccine action plan. (2013). Vaccine, 31, B5-B31. doi:10.1016/j.vaccine.2013.02.015.

Australia introduced rotavirus vaccines into the routine program in 2007, and analyses have found them to be cost-saving. From 2007-2012 rotavirus vaccines were credited with cost savings to the tune of A$66 million over the six-year period, an unexpected benefit due in part to the indirect effects of vaccination—a reduction in rotavirus in older children, often diagnosed as unspecified gastroenteritis.Reyes, J. F., et al., Beyond expectations: Post-implementation data shows rotavirus vaccination is likely cost-saving in Australia. Vaccine 2017, 35 (2), 345–352.

Among European countries, Austria was one of the first to introduce rotavirus vaccine in 2006. Favorable cost calculations were among the leading factors that led Austria to implement Rotateq, and later ROTARIX, through a universal mass vaccination (UMV) program for all infants between the ages of 6 weeks and 6 months.https://bmcinfectdis.biomedcentral.com/articles/10.1186/1471-2334-13-112https://pubmed.ncbi.nlm.nih.gov/11224839. A 2008 follow-up study found rotavirus gastroenteritis (RVGE) hospitalizations had declined by 74% in comparison to the 2001-2006 pre-vaccination years.https://pubmed.ncbi.nlm.nih.gov/19935446/ In addition, a decrease in RVGE cases was also observed in children who were too young to be fully vaccinated in the mass vaccination program as well as older children 32 months to <60 months who were born before the program was implemented or otherwise excluded by the program’s age limitations, suggesting benefits from the effects of herd protection.https://pubmed.ncbi.nlm.nih.gov/21320539/https://www.clinicalmicrobiologyandinfection.com/article/S1198-743X(15)00286-4/fulltext#bib14

The Rotavirus Accelerated Vaccine Introduction Network (RAVIN) project supported Bangladesh in preparing for the introduction of rotavirus vaccine. The planning process of RVV has been delayed through various obstacles, including cold-chain expansion requirements, infrastructure challenges, leadership turnover, and competing campaign priorities. However, through patience and persistence, RVV can expect to be introduced in a country that very much needs it. In 2016, 64% of diarrheal hospitalizations in children <5 were due to rotavirus. 1,200 children in Bangladesh die annually of rotavirus disease, and 3 million children are without access to rotavirus vaccine. In addition to health impact, rotavirus has significant economic impact, as one diarrheal disease hospitalization can cost poor families more than 1/5 of their monthly income.  

Benin introduced nation-wide rotavirus vaccination in December 2019 and launched a major communication campaign to raise awareness. Opinion leaders of communities were involved in awareness-raising meetings, and for the first time, advocates utilized an entirely new way of disseminating information — through educational songs, community theatre, and artistic sketches. These outreach materials maximized coverage as they were produced in 6 different languages, and played on the radio, television, and distributed to sanitary zones. Pairing these resources along with community shout-outs, social mobilizers, and direct communication will prove to be best practices in increasing coverage.  

In Bolivia, the first low-income country to introduce GSK’s Rotarix, vaccination was demonstrated to be as effective after the introduction as it was during clinical studies. Vaccinated children were 70% less likely to be hospitalized for rotavirus-related diarrhea than unvaccinated children. The vaccine was also shown to maintain effectiveness over time, protecting children across the first two years of life, when the risk of infection is highest. Furthermore, the vaccine provided broad protection, even against strains of rotavirus not included in the vaccine.Patel MM, Patzi M, Pastor D, Nina A, Roca Y, Alvarez L, et al. Effectiveness of monovalent rotavirus vaccine in Bolivia: case-control study. BMJ. 2013;346:f3726.

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. With more emphasis on the health and economic impact, studies revealed high protection (~85%) against severe rotavirus disease and total medical savings of US$19.3 million with universal vaccination.Ruiz-Palacios GM, Pérez-Schael I, Velázquez FR, et al. Safety and efficacy of an attenuated vaccine against severe rotavirus gastroenteritis. N Engl J Med. 2006;354(1):11-22. doi:10.1056/NEJMoa052434.Constenla DO, Linhares AC, Rheingans RD, Antil LR, Waldman EA, da Silva LJ. Economic impact of a rotavirus vaccine in Brazil. J Health Popul Nutr. 2008;26(4):388-396. doi:10.3329/jhpn.v26i4.1880.

Brazil became the first country to launch rotavirus vaccination into the public sector in 2006 and sustained high levels of coverage (≥80%) from 2007-2018.

The DRC has one of the world’s highest rotavirus mortality rates at 103 per 100,000 people (2017). With over 13,500 deaths annually and 67% of diarrheal hospitalizations due to rotavirus, introducing the vaccine was a top priority. ROTASIIL was introduced to the DRC’s national immunization program in 2019, but not without challenges. The DRC made major changes in its product selection, requiring vast adaptations to inform local decision-makers on the products, cold chain implications, benefits, challenges, and administration. Overall, the planning and introduction of ROTASIIL in the DRC proved to be an opportunity to build technical knowledge and professional networks, strengthen in-country immunization networks, and expand cold chain capacity.

India’s decision to introduce rotavirus vaccine represents a major step forward in increasing global access to these vaccines. The Government of India phased the introduction, with partial support from Gavi over several years, rolling out rotavirus vaccines nationally.John, J., et al., Rotavirus gastroenteritis in India, 2011-2013: Revised estimates of disease burden and potential impact of vaccines. Vaccine 2014, 32 (S1), 1 A5–A9. A major factor was the development, clinical testing, and licensure of two locally-produced vaccines, ROTAVAC® and ROTASIIL®. Another key step was the establishment of a rotavirus surveillance network in the early 2000s, which greatly increased evidence of the prevalence and severity of rotavirus in Indian children.

In Mexico, sharp declines in diarrheal deaths among children were observed following rotavirus vaccine introduction in 2007. During the 2009 rotavirus season, all-cause diarrhea deaths dropped by more than 65% among children age 2 and younger.Richardson V, Hernandez-Pichardo J, Quintanar-Solares M, Esparza-Aguilar M, Johnson B, Gomez-Altamirano CM, et al. Effect of rotavirus vaccination on death from childhood diarrhea in Mexico. N Engl J Med. 2010;362(4):299-305. The drastic reduction of child deaths and diarrhea-related hospitalizations in Mexico demonstrated the public health value of nationwide rotavirus vaccination and provided other countries with evidence of real-world impact.Quintanar-Solares M, Yen C, Richardson V, Esparza-Aguilar M, Parashar UD, Patel MM. Impact of rotavirus vaccination on diarrhea-related hospitalizations among children < 5 years of age in Mexico. Pediatr Infect Dis J. 2011;30(1 Suppl):S11-5. In the four years following vaccine introduction, Mexico observed sustained reductions in diarrhea deaths among children under 5 years old—by half (50%).Richardson V, Parashar U, Patel M. Childhood diarrhea deaths after rotavirus vaccination in Mexico. N Engl J Med. 2011;365(8):772-3.Gastanaduy PA, Sanchez-Uribe E, Esparza-Aguilar M, Desai R, Parashar UD, Patel M, et al. Effect of rotavirus vaccine on diarrhea mortality in different socioeconomic regions of Mexico. Pediatrics. 2013;131(4):e1115-20.

Nepal recognized the need to introduce rotavirus vaccine into the national immunization program as rotavirus is responsible for one-quarter of all diarrheal hospitalizations in children <5. The process of introducing a new vaccine was made even more complex due to Nepal’s recent decentralization, requiring greater coordination among all partners and stakeholders involved. Health workers were trained at the federal and provincial levels, gaining deeper understandings of disease prevention, routine immunization, hygiene promotion strategies, and additional approaches to reduce children’s risk of diarrheal disease while increasing rotavirus vaccine coverage.

Nicaragua became one of the earliest adopters of routine rotavirus vaccination among lower-middle income countries after a sweeping outbreak in 2005 elevated rotavirus vaccine introduction among the nation’s public health priorities.Amador JJ, Vasquez J, Orozco M, et al. Rotavirus disease burden, Nicaragua 2001-2005: defining the potential impact of a rotavirus vaccination program. Int J Infect Dis. 2010;14(7), E592-E595. DOI:10.1016/j.ijid.2009.08.014Ulloa-Gutierrez R, Avila-Aguero ML. Rotavirus vaccination in Central American children. Expert Rev. Vaccines. 2014;13(6), 687-690. DOI: 10.1586/14760584.2014.905747 Prior to rotavirus vaccine introduction in 2006, an estimated 28% of children in Nicaragua would visit a Ministry clinic for treatment of rotavirus-associated diarrhea by the age of five, and 3% of children would require hospitalization.Amador JJ, Vasquez J, Orozco M, et al. Rotavirus disease burden, Nicaragua 2001-2005: defining the potential impact of a rotavirus vaccination program. Int J Infect Dis. 2010;14(7), E592-E595. DOI:10.1016/j.ijid.2009.08.014

A key aspect of Nicaragua’s vaccine introduction is that it was facilitated by a public-private partnership between Nicaragua’s Ministry of Health and Merck, the manufacturer of RotaTeq pentavalent vaccine.Khawaja S, Cardellino A, Klotz D, et al. Evaluating the health impact of a public-private partnership. Hum. Vaccines Immunother. 2012;8(6), 777-782. DOI: 10.4161/hv.19757 Through the RotaTeq Nicaragua Partnership, Merck committed to providing enough vaccine supply to cover every eligible infant in Nicaragua for 3 years (over 1.3 million doses).Khawaja S, Cardellino A, Klotz D, et al. Evaluating the health impact of a public-private partnership. Hum. Vaccines Immunother. 2012;8(6), 777-782. DOI: 10.4161/hv.19757 Moreover, the program aimed to integrate into the country’s existing vaccine delivery infrastructure and promote long-term sustainability to ensure continuance of the vaccine program beyond three years. By the end of the partnership in 2009, Nicaragua had achieved coverage over 90%, one of the highest rotavirus vaccination rates in the world at that time.Khawaja S, Cardellino A, Klotz D, et al. Evaluating the health impact of a public-private partnership. Hum. Vaccines Immunother. 2012;8(6), 777-782. DOI: 10.4161/hv.19757

While the national immunization advisory committee recommended that the country include rotavirus vaccine in its national immunization program in 2011, the actual introduction of rotavirus vaccine in Pakistan began as an initiative by the Punjab provincial government. With strong political leadership, Punjab began a pilot introduction in six districts in 2016 using its own funds. After Pakistan secured Gavi support for nationwide introduction, the vaccine was rolled out in the rest of Punjab province in 2017. This phased approach allowed time for each province to expand its cold chain capacity and make other preparations to ensure a successful introduction. The last province, Baluchistan, launched the vaccine in early 2018.

Rwanda has been a model early adopter of new vaccines among the African region, as the nation was one of the first low-income countries to introduce pneumococcal vaccine in 2009 and HPV vaccine in 2011.Rotavirus Vaccine in Mother and Child Week in Rwanda. WHO Africa. https://www.afro.who.int/news/rotavirus-vaccine-mother-and-child-week-rwanda. Published May 25, 2012. Accessed August 16, 2021. In May 2012, Rwanda added Rotateq to their routine immunization schedule and set a precedent as the first low-income country in Africa to introduce rotavirus vaccines.Rotavirus Vaccine in Mother and Child Week in Rwanda. WHO Africa. https://www.afro.who.int/news/rotavirus-vaccine-mother-and-child-week-rwanda. Published May 25, 2012. Accessed August 16, 2021.Sibomana H, Rugambwa C, Mwenda JM, et al. Impact of routine rotavirus vaccination on all-cause and rotavirus hospitalizations during the first four years following vaccine introduction in Rwanda. Vaccine. 2018;36(47), 7135-7141. https://doi.org/10.1016/j.vaccine.2018.01.072. Accessed August 16, 2021. High coverage levels were quickly reached after introduction, with 93% of age-eligible children vaccinated by the end of the year and up to 98% coverage maintained thereafter through 2019.Sibomana H, Rugambwa C, Mwenda JM, et al. Impact of routine rotavirus vaccination on all-cause and rotavirus hospitalizations during the first four years following vaccine introduction in Rwanda. Vaccine. 2018;36(47), 7135-7141. https://doi.org/10.1016/j.vaccine.2018.01.072. Accessed August 16, 2021.Rwanda: WHO and UNICEF estimates of immunization coverage: 2019 revision. WHO. https://www.who.int/immunization/monitoring_surveillance/data/rwa.pdf. Published July 6, 2020. Accessed August 16, 2021. Despite concerns about the protective efficacy of oral rotavirus vaccines in low-income and high-mortality settings, research suggests that in the first few years after vaccine introduction in Rwanda, rotavirus-associated acute gastroenteritis hospitalizations declined by up to 70% and rotavirus-associated diarrhea hospitalizations were reduced by up to 44% among children under five.Rwanda: WHO and UNICEF estimates of immunization coverage: 2019 revision. WHO. https://www.who.int/immunization/monitoring_surveillance/data/rwa.pdf. Published July 6, 2020. Accessed August 16, 2021. Ngabo F, Tate JE, Gatera M, et al. Effect of pentavalent rotavirus vaccine introduction on hospital admissions for diarrhoea and rotavirus in children in Rwanda: a time-series analysis. Lancet Glob Health. 2016;4(2), E129-E136. https://doi.org/10.1016/S2214-109X(15)00270-3. Accessed August 16, 2021.

Prior to rotavirus vaccine introduction, diarrhea was responsible for approximately 11% of deaths among South African children under the age of five. Msimang VMY, Page N, Groome MJ, et al. Impact of Rotavirus Vaccine on Childhood Diarrheal Hospitalization After Introduction Into the South African Public Immunization Program. J Pediatr. Infect. Dis. 2013;32(12),1359-1364. doi: 10.1097/INF.0b013e3182a72fc0 In August 2009, South Africa became the first country in the WHO African region to introduce rotavirus vaccine when it added ROTARIX to its routine childhood immunization program.Seheri LM, Page NA, Mawela MPB, et al. Rotavirus vaccination within the South African Expanded Programme on Immunisation. Vaccine. 2012;30(3), C14-C20. doi: 10.1016/j.vaccine.2012.04.018 The vaccine has had a substantial impact in reducing diarrhea hospitalizations among children; in the first two years after introduction, rotavirus hospitalizations among children under five were 54% and 58% lower in 2010 and 2011, respectively.Msimang VMY, Page N, Groome MJ, et al. Impact of Rotavirus Vaccine on Childhood Diarrheal Hospitalization After Introduction Into the South African Public Immunization Program. J Pediatr. Infect. Dis. 2013;32(12),1359-1364. doi: 10.1097/INF.0b013e3182a72fc0

Read more on South Africa’s rotavirus vaccine introduction in our interview with Dr. Michelle Groome.

In Uganda, rotavirus is the cause of approximately 40% of all diarrheal cases and is estimated to be accountable for over 7% of deaths among Ugandan children under 5 years old.Government launches new Rotavirus vaccine to protect children in Uganda from diarrhea. WHO Africa. https://www.afro.who.int/news/government-launches-new-rotavirus-vaccine-protect-children-uganda-diarrhea. Published June 26, 2018. Accessed Aug 3, 2021.Sigei C, Odaga J, Mvundura M, et al. Cost-effectiveness of rotavirus vaccination in Kenya and Uganda. Vaccine. 2015;33 Suppl 1:A109-A118. doi:10.1016/j.vaccine.2014.12.079 Beyond devastating health implications, rotavirus also poses a substantial economic burden on the country across both the health system and household levels. Rotavirus vaccine introduction therefore demonstrated the potential to be highly cost-effective for the country.Sigei C, Odaga J, Mvundura M, et al. Cost-effectiveness of rotavirus vaccination in Kenya and Uganda. Vaccine. 2015;33 Suppl 1:A109-A118. doi:10.1016/j.vaccine.2014.12.079 Uganda successfully introduced ROTARIX into their national immunization schedule in June 2018, despite shortages in rotavirus vaccine supply that postponed planned introductions in other countries that same year.Government launches new Rotavirus vaccine to protect children in Uganda from diarrhea. WHO Africa. https://www.afro.who.int/news/government-launches-new-rotavirus-vaccine-protect-children-uganda-diarrhea. Published June 26, 2018. Accessed Aug 3, 2021.Rotavirus vaccine support – Gavi’s impact. Gavi. https://www.gavi.org/types-support/vaccine-support/rotavirus. Updated Sept 29, 2020. Accessed Aug 3, 2021.

In 2006, the United States became the first country to include one of the currently available rotavirus vaccines in its national immunization program. Since then, millions of American children have been vaccinated, and dramatic reductions in hospitalizations and illnesses have been achieved. In the first four years of their use in the United States, rotavirus vaccines prevented more than 176,000 hospitalizations, 242,000 emergency department visits and 1.1 million doctors’ visits among children under age 5, resulting in nearly US$1 billion in savings Leshem E, Moritz RE, Curns AT, Zhou F, Tate JE, Lopman BA, et al. Rotavirus vaccines and health care utilization for diarrhea in the United States (2007-2011). Pediatrics. 2014;134(1):15-23.. Rotavirus hospitalizations also declined by up to 83% (60-83%) and all-cause diarrhea hospitalizations declined by up to 50% (29-50%) in children under 5 Cortese MM, Tate JE, Simonsen L, Edelman L, Parashar UD. Reduction in gastroenteritis in United States children and correlation with early rotavirus vaccine uptake from national medical claims databases.Pediatr Infect Dis J. 2010;29(6):489-94. Eberly MD, Gorman GH, Eide MB, Olsen CH, Rajnik M. The effect of rotavirus immunization on rotavirus gastroenteritis hospitalization rates in military dependents. Vaccine. 2011;29(4):650-9.. The typical United States rotavirus season, peaking in the winter and spring months, became shorter and less consistent following vaccine introduction Tate JE, Haynes A, Payne DC, Cortese MM, Lopman BA, Patel MM, et al. Trends in national rotavirus activity before and after introduction of rotavirus vaccine into the national immunization program in the United States, 2000 to 2012. Pediatr Infect Dis J. 2013;32(7):741-4..