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New Vaccines in Routine Immunisation:

Pentavalent and Rotavirus


Panna Choudhury
Vice Chairman
Child Health Foundation
pannachoudhury@gmail.com
Indias Under 5 mortality highest in the world
There has been a consistent decline in Under-Five Mortality
Rate (U5MR) in India. The rate of decline in current decade is
higher than in the previous.
However India remains the epicenter of childhood deaths and
at the current rate of decline, India is unlikely to meet the
target for Millennium Development Goal (MDG)-4, which
aims to reduce childhood mortality by two thirds to 42/1000
live birth by 2015
The UN report 'Levels and Trends in Child Mortality 2014',
found that India registered 1.34 million under-five deaths in
2013, which is still the highest in the world.
Pneumonia
24%
Diarrhea
13%
Measles
3%
Meningitis
2%
Injury
3%
Preterm birth
complications
18%
Intrapartum
complications
10%
Neonatal
infection*
8%
Congenital
abnormalities
4%
Other
15%
Liu, et al. 2012 Lancet 379:2151-61
Causes of death in Indian Children Under 5
4 things to remember about Pneumonia

ONE.
Pneumonia is the leading killer of under-5 children worldwide
In India it kills nearly 295000 children annually highest in the world
(Source: Committing to Child Survival, A Promise Renewed Progress Report, UNICEF
2013)


A Jumbo jet full of children crashing
every 8 hours
A school bus full of young
children dying in a crash every hour
4 things to remember about Pneumonia
TWO.
Bacteria causes the most severe forms of pneumonia
Pneumonia, a severe infection that affects the lungs, can be caused by
bacteria, viruses or fungi. Bacteria cause the most severe forms of
pneumonia.
The bacteria Streptococcus pneumoniae, or pneumococcus, is the
most common cause of severe pneumonia among children living in the
developing world.
Haemophilus influenzae type b (Hib) is another common bacterial
cause of pneumonia. Together they cause 50% of the total pneumonia
deaths

4 things to remember about Pneumonia
THREE.
Diagnosing and appropriately treating pneumonia is challenging
Pneumonia in children is diagnosed most often by clinical symptoms.
However, the clinical symptoms of bacterial and viral pneumonia are
similar, making it difficult for providers to distinguish between these two
causes. This can make appropriate treatment of pneumonia difficult.
Chest x-rays and laboratory tests can be helpful in confirming
pneumonia and determining its cause but use of these tools is limited by
cost and technical challenges.
Further, parents and caregivers may be unable to recognize the danger
signs of pneumonia, or may face barriers in accessing medical care for
their children, such as cost and distance.
4 things to remember about Pneumonia
FOUR.
Pneumonia prevention and treatment is possible, and can save
millions of lives through comprehensive approach
Protection: Ensuring adequate nutrition, including exclusive
breastfeeding, reducing environmental risk factors, such as
overcrowding in homes, exposure to tobacco smoke and indoor air
pollution can help protect children from pneumonia. .
Prevention: The use of vaccines against pneumococcus, Hib and other
diseases can help prevent pneumonia before it occurs.
Treatment: Early diagnosis of pneumonia to ensure that children
receive early and appropriate medical care is critical.
Hib Vaccine
Hib Vaccine is available to protect children
against Haemophilus influenzae type b (Hib), which is a major
cause of severe pneumonia, as well as meningitis.
In India the Hib vaccine is available as pentavalent vaccine in
UIP. Pentavalent contains 5 vaccines in one shot - DPT + Hep
B + Haemophilus influenzae b
Government has introduced pentavalent vaccine in 9 states
and will be introducing in another 11 states soon. Bihar is one
of the states


3 things to remember about Hib vaccines
Hib vaccine is safe and and has been in widespread use in
developed countries for more than 20 years and in some
developing countries for more than 10 years.

189 countries have introduced a Hib-containing vaccine into
their National Immunization Program; four of these have
introduced subnationally. (source: IVAC-VIMS-Report-2014-Mar.pdf)

Many countries have shown significant decline in Hib
meningitis after the introduction of the vaccine


The Million Death Study Collaborators. Causes of neonatal and child mortality in India: a nationally
representative mortality survey. Lancet 2010
Proportion of deaths due to diarrhea for children 1-59
months
Diarrheal diseases in states
4 things to remember about Rotavirus Diarrhea
ONE.
Diarrhea is one of the leading killer of under-5 children
worldwide and rotavirus is the most common cause of severe
diarrhea
Globally, rotavirus takes the lives of more than 450,000 children each
year and hospitalizes millions more.
In India, diarrhea causes approx. 141,400 deaths. Rotavirus causes
over 50,000 deaths.
Beyond these deaths, the burden of rotavirus is substantial; one
study estimated 457,000-884,000 hospitalized cases and over 2 million
outpatient visits in 2007; another suggested the burden is even higher,
approximately 600,000 to 1 million hospitalizations and 5-8 million
outpatient visits




India: multiple studies show rotavirus largest cause
of moderate-to-severe diarrhea in children <5
Rotavirus Detection Rates in Children <5 from
Surveillance at 6 Hospitals in India
2005-2007
Kang, JID, 2009
Incidence of Moderate-to-Severe Diarrhea in
Children <5 in Kolkata, India, by Cause
2007-2011
GEMS India Factsheet
(supplemental materials for
Kotloff, Lancet, 2013)
TWO.
Rotavirus is highly contagious and cannot be treated with
antibiotics or other drugs.

While mild rotavirus infections can be treated effectively in the same
manner as other forms of diarrhea, by providing fluids and salts (oral
rehydration therapy), children with severe rotavirus diarrhea can
become dehydrated and often need intravenous fluids or they risk
dying. Where this type of urgent care is inaccessible or unavailable,
rotavirus prevention through vaccination is critical to saving childrens
lives.





4 things to remember about Rotavirus Diarrhea
THREE.
Rotavirus is ubiquitous and resilient, and poses a serious threat
in India

Almost every child worldwide is infected by age 5. Especially <1 yr,
most at-risk for dehydration.
Through contaminated hands and objects ; can survive on hands and
surfaces in the environment for long periods of time.

It rapidly induces severe diarrhea, vomiting, and fever, and quickly
leads to dehydration.






4 things to remember about Rotavirus Diarrhea
FOUR.
Vaccination is the best way to protect children from rotavirus

Improvements in water quality, hygiene, and sanitation stop bacteria
and parasites that cause other forms of diarrhea but do not prevent
the spread of rotavirus.

A coordinated approach that combines rotavirus vaccines with other
prevention and treatment methods, including oral rehydration
therapy, exclusive breastfeeding, zinc treatment, improvements in
water, sanitation, and hygiene, as well as proper nutrition, will achieve
the greatest impact on diarrheal disease illness and death.






4 things to remember about Rotavirus Diarrhea
Rotavirus Vaccine
India has a new, more affordable indigenous rotavirus vaccine
licensed (116E or Rotavac)
The National Technical Advisory Group on Immunization
(NTAGI) has recommended the introduction of the vaccine
Prime Ministers Office announced that rotavirus vaccine will
be added to the Universal Immunization Programme (UIP).
Worldwide Fifty-six countries have introduced rotavirus
vaccine into their National Immunization Program; six of
these countries have introduced subnationally. Forty-eight
countries have announced plans to introduce rotavirus
vaccine into their NIP. (source: IVAC-VIMS-Report-2014-
Mar.pdf)




4.1 episodes
prevented
2 episodes
prevented
6.7 episodes
prevented
4.2 episodes
prevented
Reduction in Incidence of Rotavirus Diarrhea, Low vs. Middle Income Countries
In the first year of life, incidence per 100 child-years
50% vaccine efficacy
77% vaccine efficacy
46% vaccine efficacy 72% vaccine efficacy
Madhi, NEJ M 2010
Zaman, Lancet 2010
Rotavirus vaccines: prevent disease, despite lower
vaccine efficacy levels* in low-income countries

*Reasons for lower efficacy are not well understood, but possible explanations include: higher levels of malnutrition; interference by other
microbes (high levels of infections with other viruses/bacteria); and high levels of maternal antibodies (Patel, JID, 2009)
Vaccines in India have
helped to dramatically
reduce the burden of
several common childhood
diseases.
Cases of tetanus,
diphtheria, pertussis, and
measles have decreased by
at least 84% since the
introduction of vaccines.
India has remained polio-
free since 2011.
India's success offers many
lessons to be learned for
the global community.

A comprehensive
approach towards
managing these
diseases is needed

Bihar Snapshot
Total Population 104,099,452
Total Literacy Rate 61.8%
Under-5 Mortality Rate 77
Under5 pneumonia deaths Approx. 58,000 (MDS 2005)
Under5 diarrhea deaths Approx. 51,003 (MDS 2005)
Immunization Schedule DPT3, OPV, BCG, Measles, JE
and Hep-B
Full immunization coverage 64.5%

Sources:
Census of India 2011, < http://www.census2011.co.in/states.php>
Annual Health Survey 2010-11, Census of India
Million Death Study (2005)
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