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Vaccine
journal homepage: www.elsevier.com/locate/vaccine
a r t i c l e
i n f o
Article history:
Received 17 August 2011
Received in revised form
27 September 2011
Accepted 3 October 2011
Keywords:
Rotavirus vaccine
Developing countries
a b s t r a c t
Diarrhoeal disease is one of the commonest causes of death in children, especially in developing countries
in Africa and Asia. Rotavirus has been consistently identied as the commonest pathogen associated with
severe diarrhoea. Hence, the availability of vaccines against this organism provides the opportunity to
reduce child mortality. Data from efcacy trials in developing countries in Africa and Asia showed that the
vaccine efcacy was lower than that observed in other countries. Nevertheless, the vaccines are expected
to be of signicant benet in high mortality countries in these regions. While the reports published
in this supplement add to our understanding about the performance of these vaccines in developing
countries in these regions, questions remain over the overall impact of these vaccines when used in
national programmes of developing countries in Africa and Asia, the optimal vaccination schedules and
the impact of age restrictions for vaccine use on immunization coverage. Additional research is required
to improve understanding on the performance of these vaccines in developing countries in Africa and
Asia and measures that may improve performance. Data that will assist in the denition of the optimal
immunization schedule and possibly allow relaxation of the age restrictions for vaccine use may help
in enhancing the impact of the vaccines in these countries. Finally, disease surveillance and studies are
required to document the impact of vaccination and monitor changes in disease epidemiology.
2011 World Health Organization. Published by Elsevier Ltd. All rights reserved.
The authors are staff members of the World Health Organization. The authors
alone are responsible for the views expressed in this publication and they do not necessarily represent the decisions, policy or views of the World Health Organization.
Corresponding author at: Expanded Programme on Immunization, Department
of Immunization, Vaccines and Biologicals, World Health Organization, 20 Avenue
Appia, 1211 Geneva 27, Switzerland. Tel.: +41 22 791 4460; fax: +41 22 791 4193.
E-mail address: cheriant@who.int (T. Cherian).
vaccine (RotarixTM , GlaxoSmithKline Biologicals) and a pentavalent bovine-human reassortant vaccine (RotaTeq , Merck & Co.,
Inc.) was welcome news. Both vaccines showed high efcacy
against severe rotavirus diarrhoea in industrialized countries, as
well as middle-income countries in Latin America. Following the
introduction of the vaccines, impressive declines in rotavirus
and all-cause diarrhoea hospitalizations were observed in many
countries [4]. In Mexico and Brazil 35% and 22% reductions in
diarrhoea-related mortality, respectively, were observed in children under 5 years, following the introduction of rotavirus vaccine
[5,6].
Despite the high efcacy demonstrated by the vaccines in studies in industrialized countries and in Latin America, the World
Health Organizations (WHO) Strategic Advisory Group of Experts
(SAGE) on immunization, deferred making a recommendation for
global use in 2006, pending the availability of efcacy data from
developing countries in Africa and Asia. This was based on the fact
that the efcacy of other live oral vaccines has varied between
different population groups, with efcacy being lower in developing country populations with the highest burden of disease
[7].
The rst results of the efcacy of rotavirus vaccines in developing countries in Africa and Asia were published in 2010
[810]. While these studies showed that the efcacy of both
RotarixTM and RotaTeq were lower in the populations in these
0264-410X/$ see front matter 2011 World Health Organization. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.vaccine.2011.10.007
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5. Conclusions
Rotavirus diarrhoea is an important cause of childhood morbidity and mortality world wide and particularly so in developing
countries with high child mortality. Data on rotavirus diarrhoea
and the efcacy of vaccination in developing countries is rapidly
increasing, and there is increasing evidence to suggest that the
vaccines will have a signicant effect on childhood morbidity and
mortality, despite the lower efcacy of the vaccines, in developing
country populations in Asia and Africa. However, further data are
required to fully understand and document the impact of rotavirus
vaccines in these populations. There are programmatic challenges
related to the age restrictions for delivering vaccines that might
affect the overall impact of vaccines in populations where timely
delivery of the vaccine is difcult. Data that would allow relaxation
of the age restrictions and adjuncts that might improve vaccine
performance would certainly contribute to improving the impact
of these vaccines. On the other hand, the challenges raised by
rotavirus vaccine might represent an opportunity to innovate and
improve immunization systems to improve timely delivery of vaccines, that would not only improve the impact of rotavirus vaccines,
but all childhood vaccines, in general. Continued surveillance is
required to monitor for strain changes that may alter vaccine effectiveness or that may be a result of vaccination. However, data on
strain changes need to be very carefully evaluated before attributing them to vaccination.
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[11]
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