Implementation of the World Health Organization recommendation on the use of rotavirus vaccine without age restriction by African countries

A decade of rotavirus vaccination in the World Health Organization African Region: An in-depth analysis of vaccine coverage from 2012 to 2023

BACKGROUND

Significant progress has been achieved in the introduction of rotavirus vaccines in the World Health Organization, African Region (WHO/AFR), with only 19% (9/47) of the countries yet to introduce the vaccines. Despite this achievement, a considerable number of eligible children in Africa still lack access to these lifesaving rotavirus vaccines.

METHODOLOGY

We performed in-depth data exploration and analysis on the WHO/UNICEF rotavirus vaccine uptake estimates of vaccine coverage to document progress and estimated the number of children missing vaccination through under- or un-vaccination between 2012 and 2023.

RESULTS

Thirty-eight countries have introduced the vaccine in the national immunization programs and the vaccine coverage rates have increased from 5% to 61% between 2012 and 2023 in the WHO/AFR, compared to 11% to 55% at the global level. Coverage by sub-regions ranged from 48% in Central African countries to 73% in the Southeast sub-region in 2023. Vaccine coverage has been increasing every year, yet some countries reported a significant drop during the COVID-19 pandemic (2020-2022) compared to the pre-pandemic (2019_or earlier) period. For instance, in Senegal, coverage declined from 94% to 70%; Namibia, 90% to 55%; Republic of Congo, 71% to 23 %; for 2019 and 2022, respectively. Four countries experienced a significant decline between 2021 and 2022. For instance, Botswana (85% to 65%), Kenya (95% to 23%), Zambia (87% to 32%), and Zimbabwe (86% to 55%); but coverage increased in 2023 (post-pandemic) in Kenya (71%), Senegal (83%), and Zambia (40%). The estimates of vaccinated children increased steadily over the years, reaching 23.5 million in 2023. However, 257.8 million children missed vaccination between 2012 and 2023, of which 18.5 million in 2022.

CONCLUSIONS

Although countries in the WHO/AFR have made significant progress in introducing rotavirus vaccines, reaching every eligible child remains a challenge; and more than half of children are missing the full benefit of protection against rotavirus diarrhoea. There is a need for accelerated actions and concerted efforts to reach missed children and support for the nine remaining countries to introduce the vaccine.

Impact of dosing schedules on performance of rotavirus vaccines in Ghana

There is currently limited evidence regarding how the rotavirus vaccine dosing schedule might be adjusted to improve vaccine performance. We quantified the impact of the previously implemented 6/10-week Rotarix vaccine (RV1) in Ghana to the model-predicted impact for other vaccine dosing schedules across three hospitals and the entire country. Compared to no vaccination, the model-estimated median percentage reductions in rotavirus ranged from 28 to 85% and 12 to 71% among children <1 and <5 years old, respectively. The median predicted reductions in rotavirus for the whole country ranged from 57 to 66% among infants <1 year and 35 to 45% among children <5 years old. The 1/6/10- and 6/10/14-week schedules provided the best and comparable reductions in rotavirus compared to the original 6/10-week schedule. A third dose could prevent an additional 9 to 14% of deaths. An additional dose of RV1 might be an effective strategy to improve rotavirus vaccine impact, particularly in settings with low vaccine effectiveness.

Rotavirus infections and their genotype distribution pre- and post-vaccine introduction in Ethiopia: a systemic review and meta-analysis

BACKGROUND

Rotavirus infections are a significant cause of severe diarrhea and related illness and death in children under five worldwide. Despite the global introduction of vaccinations for rotavirus over a decade ago, rotavirus infections still result in high deaths annually, mainly in low-income countries, including Ethiopia, and need special attention. This system review and meta-analysis aimed to comprehensively explore the positive proportion of rotavirus at pre- and post-vaccine introduction periods and genotype distribution in children under five with diarrhea in Ethiopia.

METHODS

The review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines. Database sources included PubMed, Scopus, EMBASE, and Epistemonikos, focusing on studies published before November 30, 2023. The search targeted rotavirus infection and genotype distribution in Ethiopia before and after the introduction of the Rota vaccine. Data was managed using EndNote 2020 software and stored in an Excel 2010 sheet. A random-effects model determined the pooled estimate of the rotavirus infection rate at 95% confidence intervals. The Q-and I² statistics were used to assess the study heterogeneity, and a funnel plot (Egger test) was used to determine the possibility of publication bias.

RESULTS

The analysis included data from nine studies conducted in different regions of Ethiopia. The overall prevalence of rotavirus infection was significant, with a prevalence rate of approximately 22.63% (1362/6039). The most common genotypes identified before the Rota vacation introduction were G1, G2, G3, G12, P [4], P [6], P [8], P [9], and P [10]. Meanwhile, G3 and P [8] genotypes were particularly prevalent after the Rota vaccine introduction. These findings highlight the importance of implementing preventive measures, such as vaccination, to reduce the burden of rotavirus infection in this population. The identified genotypes provide valuable insights for vaccine development and targeted interventions.

CONCLUSION

This study contributes to the evidence base for public health interventions and strategies to reduce the impact of rotavirus infection in children under five in Ethiopia. Despite the rollout of the Rota vaccination in Ethiopia, rotavirus heterogeneity is still high, and thus, enhancing vaccination and immunization is essential.

Impact of dosing schedules on performance of rotavirus vaccines in Ghana

Background

Available live-oral rotavirus vaccines are associated with low to moderate performance in low- and middle-income settings. There is limited evidence relating to how the vaccine dosing schedule might be adjusted to improve vaccine performance in these settings.

Methods

We used mathematical models fitted to rotavirus surveillance data for children <5 years of age from three different hospitals in Ghana (Korle-Bu Teaching Hospital in Accra, Komfo Anokye Teaching Hospital in Kumasi and War Memorial Hospital in Navrongo) to project the impact of rotavirus vaccination over a 10-year period (April 2012-March 2022). We quantified and compared the impact of the previous vaccination program in Ghana to the model-predicted impact for other vaccine dosing schedules across the three hospitals and the entire country, under different assumptions about vaccine protection. To project the rotavirus vaccine impact over Ghana, we sampled from the range of model parameters for Accra and Navrongo, assuming that these two settings represent the "extremes" of rotavirus epidemiology within Ghana.

Results

For the previously implemented 6/10-week monovalent Rotarix vaccine (RV1) schedule, the model-estimated average annual incidence of moderate-to-severe rotavirus-associated gastroenteritis (RVGE) ranged between 1,151 and 3,002 per 100,000 people per year over the 10-year period for the three sites. Compared to no vaccination, the model-estimated median percentage reductions in RVGE ranged from 28-85% and 12-71% among children <1 year and <5 years of age respectively, with the highest and lowest percentage reductions predicted using model parameters estimated for Accra and Navrongo, respectively. The median predicted reductions in RVGE for the whole country ranged from 57-66% and 35-45% among children <1 year and <5 years of age, respectively. The 1/6/10- and 6/10/14-week schedules provided the best and comparable reductions in RVGE compared to the original 6/10-week schedule, whereas there was no improvement in impact for the 10/14-week schedule.

Conclusions

We found that administering an additional dose of RV1 might be an effective strategy to improve rotavirus vaccine impact, particularly in settings with low vaccine effectiveness. The results could be extrapolated to other countries using a 2-dose vaccine schedule with low to moderate vaccine performance.

Lessons Learned and Future Perspectives for Rotavirus Vaccines Switch in the World Health Organization, Regional Office for Africa

BACKGROUND

Following the World Health Organization (WHO) recommendation, 38/47 countries have introduced rotavirus vaccines into the program of immunization in the WHO Regional Office for Africa (WHO/AFRO). Initially, two vaccines (Rotarix and Rotateq) were recommended and recently two additional vaccines (Rotavac and Rotasiil) have become available. However, the global supply challenges have increasingly forced some countries in Africa to switch vaccine products. Therefore, the recent WHO pre-qualified vaccines (Rotavac, Rotasiil) manufactured in India, offer alternatives and reduce global supply challenges related to rotavirus vaccines; Methods: Using a questionnaire, we administered to the Program Managers, Expanded Program for Immunization, we collected data on vaccine introduction and vaccine switch and the key drivers of the decisions for switching vaccines products, in the WHO/AFRO. Data was also collected fromliterature review and the global new vaccine introduction status data base maintained by WHO and other agencies.

RESULTS

Of the 38 countries that introduced the vaccine, 35 (92%) initially adopted Rotateq or Rotarix; and 23% (8/35) switched between products after rotavirus vaccine introduction to either Rotavac (n = 3), Rotasiil (n = 2) or Rotarix (n = 3). Three countries (Benin, Democratic Republic of Congo and Nigeria) introduced the rotavirus vaccines manufactured in India. The decision to either introduce or switch to the Indian vaccines was predominately driven by global supply challenges or supply shortage. The withdrawal of Rotateq from the African market, or cost-saving for countries that graduated or in transition from Gavi support was another reason to switch the vaccine; Conclusions: The recently WHO pre-qualified vaccines have offered the countries, opportunities to adopt these cost-effective products, particularly for countries that have graduated or transitioning from full Gavi support, to sustain the demand of vaccines products.

Missed opportunities for vaccination (MOV) in children up to 5 years old in 19 Médecins Sans Frontières-supported health facilities: a cross-sectional survey in six low-resource countries

OBJECTIVE

To describe missed opportunities for vaccination (MOV) among children visiting Médecins Sans Frontières (MSF)-supported facilities, their related factors, and to identify reasons for non-vaccination.

DESIGN

Cross-sectional surveys conducted between 2011 and 2015.

SETTING AND PARTICIPANTS

Children up to 59 months of age visiting 19 MSF-supported facilities (15 primary healthcare centres and four hospitals) in Afghanistan, Democratic Republic of the Congo, Mauritania, Niger, Pakistan and South Sudan. Only children whose caregivers presented their vaccination card were included.

OUTCOME MEASURES

We describe MOV prevalence and reasons for no vaccination. We also assess the association of MOV with age, type of facility and reason for visit.

RESULTS

Among 5055 children's caregivers interviewed, 2738 presented a vaccination card of whom 62.8% were eligible for vaccination, and of those, 64.6% had an MOV. Presence of MOV was more likely in children visiting a hospital or a health facility for a reason other than vaccination. MOV occurrence was significantly higher among children aged 12-23 months (84.4%) and 24-59 months (88.3%) compared with children below 12 months (56.2%, p≤0.001). Main reasons reported by caregivers for MOV were lack of vaccines (40.3%), reason unknown (31.2%) and not being informed (17.6%).

CONCLUSIONS

Avoiding MOV should remain a priority in low-resource settings, in line with the new 'Immunization Agenda 2030'. Children beyond their second year of life are particularly vulnerable for MOV. We strongly recommend assessment of eligibility for vaccination as routine healthcare practice regardless of the reason for the visit by screening vaccination card. Strengthening implementation of 'Second year of life' visits and catch-up activities are proposed strategies to reduce MOV.

Association between childhood immunisation coverage and proximity to health facilities in rural settings: a cross-sectional analysis of Service Provision Assessment 2013-2014 facility data and Demographic and Health Survey 2015-2016 individual data in Malawi

OBJECTIVES

Despite significant progress in childhood vaccination coverage globally, substantial inequality remains. Remote rural populations are recognised as a priority group for immunisation service equity. We aimed to link facility and individual data to examine the relationship between distance to services and immunisation coverage empirically, specifically using a rural population.

DESIGN AND SETTING

Retrospective cross-sectional analysis of facility data from the 2013-2014 Malawi Service Provision Assessment and individual data from the 2015-2016 Malawi Demographic and Health Survey, linking children to facilities within a 5 km radius. We examined associations between proximity to health facilities and vaccination receipt via bivariate comparisons and logistic regression models.

PARTICIPANTS

2740 children aged 12-23 months living in rural areas.

OUTCOME MEASURES

Immunisation coverage for the six vaccines included in the Malawi Expanded Programme on Immunization schedule for children under 1 year at time of study, as well as two composite vaccination indicators (receipt of basic vaccines and receipt of all recommended vaccines), zero-dose pentavalent coverage, and pentavalent dropout.

FINDINGS

72% (706/977) of facilities offered childhood vaccination services. Among children in rural areas, 61% were proximal to (within 5 km of) a vaccine-providing facility. Proximity to a vaccine-providing health facility was associated with increased likelihood of having received the rotavirus vaccine (93% vs 88%, p=0.004) and measles vaccine (93% vs 89%, p=0.01) in bivariate tests. In adjusted comparisons, how close a child was to a health facility remained meaningfully associated with how likely they were to have received rotavirus vaccine (adjusted OR (AOR) 1.63, 95% CI 1.13 to 2.33) and measles vaccine (AOR 1.62, 95% CI 1.11 to 2.37).

CONCLUSION

Proximity to health facilities was significantly associated with likelihood of receipt for some, but not all, vaccines. Our findings reiterate the vulnerability of children residing far from static vaccination services; efforts that specifically target remote rural populations living far from health facilities are warranted to ensure equitable vaccination coverage.

Using Household Surveys to Assess Missed Opportunities for Simultaneous Vaccination: Longitudinal Examples from Colombia and Nigeria

One important strategy to increase vaccination coverage is to minimize missed opportunities for vaccination. Missed opportunities for simultaneous vaccination (MOSV) occur when a child receives one or more vaccines but not all those for which they are eligible at a given visit. Household surveys that record children’s vaccination dates can be used to quantify occurrence of MOSVs and their impact on achievable vaccination coverage. We recently automated some MOSV analyses in the World Health Organization’s freely available software: Vaccination Coverage Quality Indicators (VCQI) making it straightforward to study MOSVs for any Demographic & Health Survey (DHS), Multi-Indicator Cluster Survey (MICS), or Expanded Programme on Immunization (EPI) survey. This paper uses VCQI to analyze MOSVs for basic vaccine doses among children aged 12–23 months in four rounds of DHS in Colombia (1995, 2000, 2005, and 2010) and five rounds of DHS in Nigeria (1999, 2003, 2008, 2013, and 2018). Outcomes include percent of vaccination visits MOSVs occurred, percent of children who experienced MOSVs, percent of MOSVs that remained uncorrected (that is, the missed vaccine had still not been received at the time of the survey), and the distribution of time-to-correction for children who received the MOSV dose at a later visit.