Michelle Groome, PhD
National Institute for Communicable Diseases, South Africa
Breaking ground in Africa: Rotavirus vaccine introduction in South Africa
In this spotlight, ROTA spoke with Dr. Michelle Groome about the groundbreaking introduction of rotavirus vaccine in South Africa and the country’s efforts to overcome ongoing challenges to protect all children from rotavirus. Dr. Michelle Groome previously led the diarrheal disease portfolio at the SAMRC Respiratory and Meningeal Pathogens Research Unit where she contributed to providing the first rotavirus vaccine effectiveness data from Africa and evaluating safety and immunogenicity of a novel injectable subunit rotavirus vaccine in South Africa. Dr. Groome now serves as the Head of the Division of Public Health Surveillance and Response at the National Institute for Communicable Diseases (NCID) in South Africa.
“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.”
– Michelle Groome
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.