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New Vaccines in Routine Immunisation:

Pentavalent and Rotavirus

Panna Choudhury

Vice Chairman

Child Health Foundationpannachoudhury@gmail .com



India’s 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 andat 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%Meningitis2%Injury

3%

Preterm birthcomplications

18%

Intrapartum

complications

10%

Neonatal

infection*

8%

Congenital

abnormalities

4%

Other15%

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




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 ofpneumonia.

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 bacterialcause of pneumonia. Together they cause 50% of the total pneumonia

deaths




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 twocauses. 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.




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 asovercrowding 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 inUIP. 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 oneof the states



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 1-59months

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 children’s

lives.




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.




FOUR.

Vaccination is the best way to protect children from rotavirus

Improvements in water quality, hygiene, and sanitation stop bacteriaand parasites that cause other forms of diarrhea but do not prevent

the spread of rotavirus.

A coordinated approach that combines rotavirus vaccines with otherprevention 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.




4.1 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, NEJM 2010Zaman, 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 dramaticallyreduce the burden of

several common childhood

diseases.

• Cases of tetanus,

diphtheria, pertussis, andmeasles 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 towardsmanaging these

diseases is needed



Bihar Snapshot

• Total Population 104,099,452

• Total Literacy Rate 61.8%

• Under-5 Mortality Rate 77

• Under – 5 pneumonia deaths Approx. 58,000 (MDS 2005)

• Under – 5 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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