Council member Tony Nelson and colleagues organized a rotavirus advocacy workshop at the 13th Congress of Asian Society for Pediatric Research on October 5, 2017. Speakers from Cambodia, China, Hong Kong, Macau, Taiwan, India, Laos, Malaysia, Myanmar, Philippines, and the US discussed disease burden and vaccine impact, opportunities for vaccine introduction, currently available vaccines and new products in the pipeline, and lessons from advocacy efforts in the Asia Pacific region.
Summary below by Dr. Tony Nelson, Karene Yeung, and colleagues.
Professor Tony Nelson, of the Department of Paediatrics, the Chinese University, opened the workshop, which aimed to provide updated information on rotavirus disease burden, vaccine impact, vaccine pipeline, and country vaccine introduction plans.
Molly Sauer, of the ROTA Council, managed at John Hopkins International Vaccine Access Center, outlined the Council’s mission of accelerating the introduction of rotavirus vaccines through the use of evidence and strategic communications targeting policymakers and other key decision makers with the support of technical and advocacy materials (Ms. Sauer is pictured above).
Jackie Tate, an epidemiologist with the Viral Gastroenteritis Team at the US Centers for Disease Control and Prevention, reminded everyone that rotavirus is the most common cause of severe acute gastroenteritis in young children. Dr. Tate, pictured above, said it cannot be prevented with improvements in hygiene and sanitation.
Impact of rotavirus vaccine
Dr. Tate shared data showing that countries introducing the vaccine for universal use have seen impressive reductions in rotavirus and all-cause gastroenteritis hospitalizations and gastroenteritis mortality.
Despite lower vaccine efficacy in low-income countries, the public health impact in these high-mortality settings is greater with a higher number of severe acute rotavirus gastroenteritis prevented in high mortality settings compared with low mortality settings.
Vaccine would promote equity in Malaysia
Way Seah Lee, a professor at Malaysia’s University of Malaya Medical Centre, highlighted the role vaccines play to promote equity. In Malaysia, the poorest income quintile spent 23% of their monthly income on providing healthcare if their child required hospital care for acute gastroenteritis, with 86% of households in this quintile potentially experiencing catastrophic expenditures as a result of hospitalization. This proportion was significantly higher than all other income groups.
Although rotavirus mortality is low in Malaysia, morbidity is substantial and illness-related expenditures especially impacts the urban poor. In Malaysia, rotavirus vaccines are currently only available at private healthcare facilities at prices that are prohibitive for the poor. A publicly financed, universal rotavirus vaccination program that negotiated vaccine prices in line with other countries would likely be cost-effective and affordable in Malaysia and would increase health equity.
Professor Kyaw Linn, Yangon Children Hospital, Secretary, Myanmar Pediatric Society, Myanmar noted that ongoing sentinel surveillance of rotavirus diarrhea was being supported by WHO.
Rotavirus is accounting for approximately half of acute gastroenteritis hospitalizations among children less than 5 years of age (range from 42% in 2009 to 56% in 2011). It is anticipated that an application to include rotavirus vaccine in Myanmar’s National Immunisation Programme could be made by May 2018 with plans to launch the vaccine in 2019.
Rotavirus burden in Cambodia and Laos
Chea Choeung, Chief of Gastroenterology Department in Cambodia’s National Pediatric Hospital, reported preliminary 2013 data showing that rotavirus gastroenteritis is a significant cause of under 5 years morbidity and mortality. Active surveillance for rotavirus gastroenteritis was conducted from January 2010 through December 2016 at the National Pediatric Hospital in Phnom Penh. There are tentative plans to introduce rotavirus vaccine to the Cambodian National Immunisation Programme in 2020.
Professor Mayfong Mayxay, Vice-Dean for Research at the University of Health Sciences, Lao People’s Democratic Republic, outlined the importance of diarrhoea, malnutrition and stunting in Lao PDR. A study at Mahosot Hospital from 2009 – 2015 showed that 56% of diarrhoea admissions were due to rotavirus.
Laos applied in September 2017 for GAVI support to include rotavirus vaccine to its National Immunisation Programme.
Vaccine development collaborations between China and US CDCs
Baoming Jiang, Supervisory Research Microbiologist, Viral Gastroenteritis Branch, Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, US Centers for Disease Control and Prevention, USA provided highlights of the 1st International Meeting of Gastroenteritis Viruses, held in September 2017 in Shanghai. US and China CDC have a long history collaborating on rotavirus research. New rotavirus vaccines are being developed in China. Research on inactivated vaccines is at an earlier stage but offers future promise.
With the success of rotavirus vaccines, norovirus is being recognized as an important pathogen of diarrhoea over 600 million cases, 6 million hospitalizations, and 200,000 deaths annually. An estimated 70,000 of these deaths are in children aged under 5 years. Several candidate norovirus vaccines are in development but challenges remain.
Professor Xuan-Yi Wang, a research scientist at the Institutes of Biomedical Sciences and a professor at China’s Key Laboratory of Medical Molecular Virology of MoE/MoH, Fudan University, reported that an estimated 15 million doses (6 million per year) of the currently Lanzhou Institute monovalent lamb rotavirus vaccine have been sold in the private market during the past 11 years. The annual EPI population is approximately 15 million.
A number of vaccines are yet to be included in China’s National Immunisation Programme including rotavirus, varicella, Hib, pneumococcal conjugate vaccine, and influenza vaccines. Two rotavirus vaccines are pending licensure in China: Lanzhou’s new trivalent reassortant vaccine (more than 70% efficacy against severe rotavirus gastroenteritis) and Merck’s pentavalent reassortant vaccine.
A new National Advisory Committee on Immunization Practices was established in September 2017. Although there is no timeline for national introduction of rotavirus vaccines, it is possible that vaccine could be introduced at provincial and sub-national level.
Access to rotavirus vaccine in Taiwan and Macau
Fang-Tzy Wu, the associate director of the Foodborne Disease Research Center, and team lead for the CDC, Taiwan’s Viral Diarrheal and Enteric Disease Lab, at its Research and Diagnostics Center, noted that rotavirus vaccines are available in the private sector and approximately 50% of children receive the vaccine. During 2001-2012, there were between 800,000 and 1,220,000 episodes of acute gastroenteritis in children less than 5 years.
Hospital-based diarrhoea surveillance has been ongoing since 2014 to monitor strain surveillance and disease burden. Although rotavirus vaccine is not included in the National Immunisation Programme, approximately 50% of the birth cohort receive rotavirus vaccines and vaccine effectiveness of >90% has been documented. Taipei City has supported universal rotavirus vaccine since April 2017 but the inclusion of the vaccine in the National Immunisation Programme is necessary to ensure equity among all children in Taiwan.
Dr. Kin Mui Leong, the president of Macau’s Paediatric Society, said that Macau currently does not include rotavirus vaccine in its universal immunization programme. Macau has a small birth cohort and a high GDP per capita. Rotavirus vaccine is available privately and it is thought that approximately 50% of children receive the vaccine.
There is limited data on the territory’s rotavirus disease burden and it is unclear whether the vaccine will be considered for universal use in the foreseeable future.
Data from Hong Kong
Professor Chun-bong Chow, of the Department of Paediatrics and Adolescent Medicine, the University of Hong Kong, reviewed Hong Kong data on rotavirus disease burden, vaccine efficacy, and effectiveness. Despite the availability of these data, rotavirus vaccine has not been included in Hong Kong’s routine Childhood Immunisation Programme. More research on translating evidence to practice is needed and involvement and political empowerment of communities should be considered.
Dr. Carl Kirkwood, a Senior Program Officer at the Bill and Melinda Gates Foundation, reviewed the two rotavirus vaccines currently pre-qualified by WHO and provided updates on the nationally licensed live attenuated oral vaccines and earlier stage development of the non-replicating rotavirus vaccines.
These new vaccines potentially offer improved effectiveness, alternative approaches for delivery and schedules, better vaccine supply and diversity, and lower cost. Large countries like India, Vietnam, China, and Indonesia will likely prefer to use their own indigenous vaccines.
The role of advocacy and pediatric organizations
Professor Lulu Bravo, Professor Emeritus at the University of the Philippines in Manila, reviewed the role of advocacy and emphasized that advocates should use their voices to share ideas to persuade others and thereby create change (pictured below at left). Health professionals can provide credible voices for the value of vaccines and thus recruit other advocacy voices. The importance of political networking should not be underestimated.
Dr. Naveen Thacker, the president of the Asia Pacific Pediatric Association and a past president of the Indian Academy of Pediatrics, expanded on why we need good advocacy for rotavirus vaccine in Asia. It is important that advocacy is evidence-based and focused on the needs of the audience. Advocacy is most successful when you care deeply about the issue and when there is a common vision. There should be evidence to support your message and it is necessary to work in partnerships with other stakeholders and to have clear plan that can be executed. The role that health care professionals can play in advocacy should not be underestimated. The Asia Pacific Pediatric Association with its 23 member countries can make a “Call to Action for the introduction of rotavirus vaccine in Asia.”
Chok-wan Chan, chairman of the Hong Kong Paediatric Foundation and chairman of the Surveillance Group of the Child Health Policy for Hong Kong concluded the workshop recognizing the need for more to be done in Asia to speak up of rotavirus vaccine introduction and supporting the idea of a “Call to Action.” He emphasized the importance of strong child health policy for the promotion of equity.
AGENDA ROTACOUNCIL PRECONFERENCE ADVOCACY WORKSHOP NEW OPPORTUNITIES FOR PREVENTING ROTAVIRUS IN THE REGION TIME: 11:00 – 15:00 DATE: 5 OCT 2017 VENUE : Function Room 1, 2/F, Hong Kong Academy of Medicine, 99 Wong Chuk Hang Road
|11:15||5 min||Welcome||Tony NELSON Professor of Practice in Paediatrics Department of Paediatrics, The Chinese University Molly SAUER ROTA Council, John Hopkins University, USA|
|11:20||15 min||Rotavirus diarrhea and global impact of rotavirus vaccines on disease burden||Jackie TATE Epidemiologist, Viral Gastroenteritis Team, Division of Viral Diseases, US Centers for Disease Control and Prevention, USA|
|11:35||10 min||Opportunities for vaccine introduction :Malaysia||Way Seah LEE Professor, Department of Paediatrics, Faculty of Medicine, University of Malaya Medical Centre, Malaysia|
|11:45||10 min||Opportunities for vaccine introduction : Myanmar||KYAW LINN Professor, Yangon Children Hospital Secretary, Myanmar Pediatric Society, Myanmar|
|11:55||10 min||Opportunities for vaccine introduction : Cambodia||Chea CHOEUNG Chief of Gastroenterology Department, National Pediatric Hospital, Phnom Penh, Cambodia|
|12:05||10 min||Opportunities for vaccine introduction : Laos||Mayfong MAYXAY Vice-Dean for Research, Faculty of Postgraduate Studies, University of Health Sciences, Ministry of Health Lao People’s Democratic Republic|
|12:45||15 min||Highlights of 1st International Workshop on Gastroenteritis Viruses||Baoming JIANG Supervisory Research Microbiologist, Viral Gastroenteritis Branch, Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, US Centers for Disease Control and Prevention, USA|
|13:00||10 min||Opportunities for vaccine introduction : China||Xuan-Yi WANG Research Scientist, Institutes of Biomedical Sciences, and Professor, Key Laboratory of Medical Molecular Virology of MoE/MoH Fudan University, Peoples Republic of China|
|13:10||10 min||Opportunities for vaccine introduction : Taiwan||Fang-Tzy WU Associate Director of Foodborne Disease Research Center, Team lead, Viral Diarrheal and Enteric Disease Lab, Research and Diagnostics Center, CDC, Taiwan|
|13:20||10 min||Opportunities for vaccine introduction : Macau||Kin Mui IEONG President, Macau Paediatric Society, Macau|
|13:30||10 min||Opportunities for vaccine introduction : Hong Kong||Chun-bong CHOW Hon. Clinical Professor, Department of Paediatrics and Adolescent Medicine, The University of Hong Kong|
|14:00||15 min||Currently available vaccines and rotavirus vaccine pipeline||Carl KIRKWOOD Senior Program Officer, Enteric and Diarrheal Diseases, Bill and Melinda Gates Foundation, Seattle, USA|
|14:20||15 min||Advocacy lessons from the Philippines||Lulu BRAVO Professor Emeritus, College of Medicine, University of the Philippines Manila, Philippines|
|14:35||15 min||Advocating for rotavirus vaccine in Asia||Naveen THACKER President, Asia Pacific Pediatric Association and Past President, Indian Academy of Pediatrics, India|
|15:00||Closing Remarks||Chok-wan CHAN Chairman of the Hong Kong Paediatric Foundation Chairman of the Surveillance Group of the Child Health Policy for Hong Kong|