Umesh D Parashar

Centers for Disease Control and Prevention, Атланта, Michigan, United States

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Publications (386)2633.18 Total impact

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    ABSTRACT: Rotavirus infection is the leading cause of severe gastroenteritis among infants and young children worldwide. Before the introduction of rotavirus vaccine in the United States in 2006, rotavirus infection caused significant morbidity among U.S. children, with an estimated 55,000-70,000 hospitalizations and 410,000 clinic visits annually. The disease showed a characteristic winter-spring seasonality and geographic pattern, with annual seasonal activity beginning in the West during December-January, extending across the country, and ending in the Northeast during April-May. To characterize changes in rotavirus disease trends and seasonality following introduction of rotavirus vaccines in the United States, CDC compared data from CDC's National Respiratory and Enteric Virus Surveillance System (NREVSS), a passive laboratory reporting system, for prevaccine (2000-2006) and postvaccine (2007-2014) years. National declines in rotavirus detection were noted, ranging from 57.8%-89.9% in each of the 7 postvaccine years compared with all 7 prevaccine years combined. A biennial pattern of rotavirus activity emerged in the postvaccine era, with years of low activity and highly erratic seasonality alternating with years of moderately increased activity and seasonality similar to that seen in the prevaccine era. These results demonstrate the substantial and sustained effect of rotavirus vaccine in reducing the circulation and changing the epidemiology of rotavirus among U.S. children.
    MMWR. Morbidity and mortality weekly report 04/2015; 64(13):337-42.
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    ABSTRACT: We evaluated quantitative real-time PCR to establish the diagnosis of rotavirus gastroenteritis in a high disease burden population in Malawi using enzyme immunoassay as the gold standard diagnostic test. In 146 children with acute gastroenteritis and 65 asymptomatic children, we defined a cut-off point in cycle threshold value (26.7) that predicts rotavirus-attributable gastroenteritis in this population. These data will inform the evaluation of direct and indirect rotavirus vaccine effects in Africa. Copyright © 2015, American Society for Microbiology. All Rights Reserved.
    Journal of clinical microbiology 04/2015; DOI:10.1128/JCM.00875-15 · 4.23 Impact Factor
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    ABSTRACT: Rotarix(TM) vaccine was introduced into the National Program of Immunization of Morocco in October 2010, reaching quickly 87% of the target population of children nationally. The incidence of rotavirus gastroenteritis and the prevalence of circulating rotavirus strains has been monitored in three sentinel hospitals since June 2006. The average percentage of rotavirus positive cases among all children under 5 years old hospitalized for gastroenteritis during the pre-vaccine period (2006-2010) was 44%. This percentage dropped to 29%, 15% and 24% in the 3 years post vaccine introduction (2011, 2012 and 2013), which is a decline of 34%, 66%, and 45%, respectively. Declines in prevalence were greatest among children 0-1 years of age (53%) and were most prominent during the winter and autumn rotavirus season. The prevalence of the G2P[4] and G9P[8] genotype sharply increased in the post vaccine period (2011-2013) compared to the previous seasons (2006-2010). Rotavirus vaccines have reduced greatly the number of children hospitalized due to rotavirus infection at the three sentinel hospitals; it is however unclear if the predominance of G2P[4] and G9P[8] genotypes is related to the vaccine introduction, or if this is attributable to normal genotype fluctuations. Continued surveillance will be pivotal to answer this question in the future. J. Med. Virol. 00:1-10, 2015. © Wiley Periodicals, Inc. © 2015 Wiley Periodicals, Inc.
    Journal of Medical Virology 03/2015; 87(6). DOI:10.1002/jmv.24122 · 2.22 Impact Factor
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    ABSTRACT: Rotavirus is the main cause of severe acute gastroenteritis in children in Africa. Monovalent human rotavirus vaccine (RV1) was added into Malawi's infant immunisation schedule on Oct 29, 2012. We aimed to assess the impact and effectiveness of RV1 on rotavirus gastroenteritis in the 2 years after introduction. From Jan 1, 2012, to June 30, 2014, we recruited children younger than 5 years who were admitted into Queen Elizabeth Central Hospital, Blantyre, Malawi, with acute gastroenteritis. We assessed stool samples from these children for presence of rotavirus with use of ELISA and we genotyped rotaviruses with use of RT-PCR. We compared rotavirus detection rates in stool samples and incidence of hospital admittance for rotavirus in children from Jan 1 to June 30, in the year before vaccination (2012) with the same months in the 2 years after vaccination was introduced (2013 and 2014). In the case-control portion of our study, we recruited eligible rotavirus-positive children from the surveillance platform and calculated vaccine effectiveness (one minus the odds ratio of vaccination) by comparing infants with rotavirus gastroenteritis with infants who tested negative for rotavirus, and with community age-matched and neighbourhood-matched controls. We enrolled 1431 children, from whom we obtained 1417 stool samples (99%). We detected rotavirus in 79 of 157 infants (50%) before the vaccine, compared with 57 of 219 (40%) and 52 of 170 (31%) in successive calendar years after vaccine introduction (p=0·0002). In the first half of 2012, incidence of rotavirus hospital admission was 269 per 100 000 infants compared with 284 in the same months of 2013 (rise of 5·8%, 95% CI -23·1 to 45·4; p=0·73) and 153 in these months in 2014 (a reduction from the prevaccine period of 43·2%, 18·0-60·7; p=0·003). We recruited 118 vaccine-eligible rotavirus cases (median age 8·9 months; IQR 6·6-11·1), 317 rotavirus-test-negative controls (9·4 months; 6·9-11·9), and 380 community controls (8·8 months; 6·5-11·1). Vaccine effectiveness for two doses of RV1 in rotavirus-negative individuals was 64% (95% CI 24-83) and community controls was 63% (23-83). The point estimate of effectiveness was higher against genotype G1 than against G2 and G12. Routine use of RV1 reduced hospital admissions for several genotypes of rotavirus in children younger than 5 years, especially in infants younger than 1 year. Our data support introduction of rotavirus vaccination at the WHO recommended schedule, with continuing surveillance in high-mortality countries. Wellcome Trust, GlaxoSmithKline Biologicals. Copyright © 2015 Bar-Zeev, et al. Open Access article distributed under the terms of CC BY. Published by Elsevier Ltd. All rights reserved.
    The Lancet Infectious Diseases 01/2015; DOI:10.1016/S1473-3099(14)71060-6 · 19.45 Impact Factor
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    ABSTRACT: Background Libya introduced rotavirus vaccine in October 2013. We examined pre-vaccine incidence of rotavirus hospitalizations and associated economic burden among children¿<¿5 years in Libya to provide baseline data for future vaccine impact evaluations.Methods Prospective, hospital-based active surveillance for rotavirus was conducted at three public hospitals in two cities during August 2012 - April 2013. Clinical, demographic and estimated cost data were collected from children <5 hospitalized for diarrhea; stool specimens were tested for rotavirus with a commercial enzyme immunoassay. Annual rotavirus hospitalization incidence rate estimates included a conservative estimate based on the number of cases recorded during the nine months and an extrapolation to estimate 12 months incidence rate. National rotavirus disease and economic burden were estimated by extrapolating incidence and cost data to the national population of children aged <5 years.ResultsA total of 410 children <5 years of age with diarrhea were enrolled, of whom 239 (58%) tested positive rotavirus, yielding an incidence range of 418-557 rotavirus hospitalizations per 100,000 children <5 years of age. Most (86%) rotavirus cases were below two years of age with a distinct seasonal peak in winter (December-March) months. The total cost of treatment for each rotavirus patient was estimated at US$ 679 (range: 200¿5,423). By extrapolation, we estimated 2,948 rotavirus hospitalizations occur each year in Libyan children <5 years of age, incurring total costs of US$ 2,001,662 (range: 1,931,726-2,094,005).Conclusions Rotavirus incurs substantial morbidity and economic burden in Libya, highlighting the potential value of vaccination of Libyan children against rotavirus.
    BMC Public Health 01/2015; 15(1):26. DOI:10.1186/s12889-015-1400-7 · 2.32 Impact Factor
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    ABSTRACT: Background Pneumonia and diarrhea are leading causes of death for children under five (U5). It is challenging to estimate the total number of deaths and cause-specific mortality fractions. Two major efforts, one led by the Institute for Health Metrics and Evaluation (IHME) and the other led by the World Health Organization (WHO)/Child Health Epidemiology Reference Group (CHERG) created estimates for the burden of disease due to these two syndromes, yet their estimates differed greatly for 2010.Methods This paper discusses three main drivers of the differences: data sources, data processing, and covariates used for modelling. The paper discusses differences in the model assumptions for etiology-specific estimates and presents recommendations for improving future models.ResultsIHME¿s Global Burden of Disease (GBD) 2010 study estimated 6.8 million U5 deaths compared to 7.6 million U5 deaths from CHERG. The proportional differences between the pneumonia and diarrhea burden estimates from the two groups are much larger; GBD 2010 estimated 0.847 million and CHERG estimated 1.396 million due to pneumonia. Compared to CHERG, GBD 2010 used broader inclusion criteria for verbal autopsy and vital registration data. GBD 2010 and CHERG used different data processing procedures and therefore attributed the causes of neonatal death differently. The major difference in pneumonia etiologies modeling approach was the inclusion of observational study data; GBD 2010 included observational studies. CHERG relied on vaccine efficacy studies.DiscussionGreater transparency in modeling methods and more timely access to data sources are needed. In October 2013, the Bill & Melinda Gates Foundation (BMGF) hosted an expert meeting to examine possible approaches for better estimation. The group recommended examining the impact of data by systematically excluding sources in their models. GBD 2.0 will use a counterfactual approach for estimating mortality from pathogens due to specific etiologies to overcome bias of the methods used in GBD 2010 going forward.
    BMC Infectious Diseases 01/2015; 15(1):16. DOI:10.1186/s12879-014-0728-4 · 2.56 Impact Factor
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    ABSTRACT: Rotavirus vaccines were introduced in the United States in 2006. Full-series coverage is lower than for other vaccines, and disease continues to occur. We examined variation in vaccine coverage among provider locations and correlated coverage with the detection of rotavirus in children who sought treatment of severe acute gastroenteritis (AGE). Vaccine records of children enrolled in an AGE surveillance program were obtained and children were grouped by the location that administered each child's 2-month vaccines. Cases were children with laboratory-confirmed rotavirus AGE; controls were children with rotavirus-negative AGE or acute respiratory infection. Location-level coverage was calculated using ≥1 dose rotavirus vaccine coverage among controls and classified as low (<40%), medium (≥40% to <80%), or high (≥80%). Rotavirus detection rates among patients with AGE were calculated by vaccine coverage category. Of controls, 80.4% (n = 1123 of 1396) received ≥1 dose of rotavirus vaccine from 68 locations. Four (5.9%) locations, including a NICU, were low coverage, 22 (32.3%) were medium coverage, and 42 (61.8%) were high coverage. In low-coverage locations, 31.4% of patients with AGE were rotavirus-positive compared with 13.1% and 9.6% in medium- and high-coverage locations, respectively. Patients with AGE from low-coverage locations had 3.3 (95% confidence interval 2.4-4.4) times the detection rate of rotavirus than patients with AGE from high vaccine coverage locations. We observed the highest detection of rotavirus disease among locations with low rotavirus vaccine coverage, suggesting that ongoing disease transmission is related to failure to vaccinate. Educational efforts focusing on timely rotavirus vaccine administration to age-eligible infants are needed. Copyright © 2015 by the American Academy of Pediatrics.
    Pediatrics 01/2015; 135(2). DOI:10.1542/peds.2014-0208 · 5.30 Impact Factor
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    ABSTRACT: A humanitarian emergency involves a complete breakdown of authority that often disrupts routine health care delivery, including immunization. Diarrheal diseases are a principal cause of morbidity and mortality among children during humanitarian emergencies. The objective of this study was to assess if vaccination against rotavirus, the most common cause of severe diarrhea among children, either as an addition to routine immunization program (RI) or supplemental immunization activity (SIA) would be cost-effective during a humanitarian emergency to decrease diarrhea morbidity and mortality, using Somalia as a case study. An impact and cost-effectiveness analysis was performed comparing no vaccine; two-dose rotavirus SIA and two-dose of RI for the 424,592 births in the 2012 Somali cohort. The main summary measure was the incremental cost per disability-adjusted life-year (DALY) averted. Univariate sensitivity analysis examined the extent to which the uncertainty in the variables affected estimates. If introduced in Somalia, a full-series rotavirus RI and SIA would save 908 and 359 lives, respectively, and save US$63,793 and US$25,246 in direct medical costs, respectively. The cost of a RI strategy would be US$309,458. Because of the high operational costs, a SIA strategy would cost US$715,713. US$5.30 per DALY would be averted for RI and US$37.62 per DALY averted for SIA. Variables that most substantially influenced the cost-effectiveness for both RI and SIA were vaccine program costs, mortality rate, and vaccine effectiveness against death. Based on our model, rotavirus vaccination appears to be a cost-effective intervention as either RI or SIA, as defined by the World Health Organization as one to three times the per capita Gross Domestic Product (Somalia $112 in 2011). RI would have greater health impact and is more cost effective than SIA, assuming feasibility of reaching the target population. However, given the lack of infrastructure, whether RI is realistic in this setting remains unanswered, and alternative approaches like SIA should be further examined.
    Conflict and Health 01/2015; 9:5. DOI:10.1186/s13031-015-0032-y
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    ABSTRACT: ABSTRACT In recent years, noroviruses have become recognized as an important cause of both sporadic and epidemic acute gastroenteritis (AGE), largely due to the improved availability of broadly reactive real-time RT-PCR (TaqMan-based RT-PCR) assays. While there is substantial diversity among noroviruses, one specific genotype, GII.4, is the most common etiology in sporadic and epidemic AGE. Outbreaks of norovirus AGE most commonly occur in healthcare facilities and restaurants and result in significant morbidity and mortality and substantial healthcare costs. Norovirus vaccine development is progressing, and Phase I and II human trials have shown proof-of-principle that norovirus vaccines can reduce illness and infection.
    Future Microbiology 01/2015; 10(1):53-67. DOI:10.2217/fmb.14.102 · 3.82 Impact Factor
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    The Journal of Infectious Diseases 12/2014; DOI:10.1093/infdis/jiu672 · 5.78 Impact Factor
  • Daniel C Payne, Umesh D Parashar, Benjamin A Lopman
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    ABSTRACT: We discuss recent advances in the understanding of acquired immunity and susceptibility to the two major pediatric enteric viral pathogens, norovirus and rotavirus. The prominent decline in severe rotavirus gastroenteritis in areas with mature rotavirus vaccination programmes has correspondingly unmasked the significant burden of disease associated with norovirus gastroenteritis among children. As epidemiologists and vaccinologists set their sights on this next vaccine target, we provide an update on norovirus vaccine development.In addition to these developments regarding acquired immunity, refinements to our understanding of innate susceptibility to norovirus has advanced. Significant recent advances now describe similar immunologic mechanisms in understanding susceptibility for both norovirus and rotavirus, involving histo-blood group antigenic associations, which may also prove to be genotype specific. This information can potentially be used to tailor both applied and developmental efforts to public health interventions against these important pediatric enteric viral pathogens.
    Current Opinion in Pediatrics 12/2014; 27(1). DOI:10.1097/MOP.0000000000000166 · 2.74 Impact Factor
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    Eyal Leshem, Umesh Parashar
    12/2014; DOI:10.1093/jpids/piu114
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    ABSTRACT: We assessed whether birth during rotavirus season modifies rotavirus vaccine effectiveness (VE), using data from rotavirus VE studies. In the first year of life, adjusted VE was 72% for children born in rotavirus season and 84% with children born in other months (P = .01). Seasonal factors may interfere with vaccine performance. © The Author 2014. Published by Oxford University Press on behalf of the Infectious Diseases Society of America. All rights reserved. For Permissions, please e-mail: journals.permissions@oup.com.
    Clinical Infectious Diseases 12/2014; DOI:10.1093/cid/ciu956 · 9.42 Impact Factor
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    Daniel E Velasquez, Umesh D Parashar, Baoming Jiang
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    ABSTRACT: To analyze the prevalence of acute asymptomatic group A and C rotavirus (RV-A and RV-C) infection in neonates with cholestasis. Participants were infants <180 days of age with cholestasis (serum direct or conjugated bilirubin >20% of total and ≥2 mg/dL) enrolled in the Childhood Liver Disease Research and Education Network during RV season (December-May). Forty infants with biliary atresia (BA), age 62 ± 29 days (range, 4.7-13 weeks) and 38 infants with cholestasis, age 67 ± 44 days (range, 3-15.8 weeks) were enrolled. At enrollment, RV-A IgM positivity rates did not differ between infants with BA (10%) vs those without (18%) (P = .349). RV-C IgM was positive in 0% of infants with BA vs 3% in those without BA (P = .49). RV-A IgG was lower in infants with BA: 51 ± 39 vs 56 ± 44 enzyme-linked immunoassay unit, P = .045 but this difference may lack biological relevance as maternal RV-A IgG titers were similar between groups. Infant RV-A IgM titers at 2-6 months follow-up increased markedly vs at presentation in both infants with BA (50 ± 30 vs 9 ± 9) and those without (43 ± 18 vs 16 ± 20 enzyme-linked immunoassay unit) (P < .0001), without differences between groups. RV-A infection in the first 6 months of life is common in infants with cholestasis of any cause. RV-A could have different pathogenetic effects by initiating different hepatic immune responses in infants with vs without BA or could lack pathogenetic significance. Copyright © 2014 Elsevier Inc. All rights reserved.
    Journal of Pediatrics 10/2014; DOI:10.1016/j.jpeds.2014.09.033 · 3.74 Impact Factor
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    Daniel E Velasquez, Umesh D Parashar, Baoming Jiang
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    ABSTRACT: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
    Infection Genetics and Evolution 10/2014; DOI:10.1016/j.meegid.2014.10.008 · 3.26 Impact Factor
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    ABSTRACT: Background: An estimated 179 million acute gastroenteritis (AGE) illnesses occur annually in the United States. Many AGE outbreaks attributed to norovirus occur in healthcare settings. The role of norovirus in healthcare-related AGE has important implications for the development and implementation of preventive strategies, but the burden has not been well-documented in U.S. acute care facilities. We estimated the incidence of community- and hospital-acquired norovirus AGE at four geographically distinct Veterans Affairs (VA) Medical Centers and their associated outpatient clinics in Atlanta, GA; Bronx, NY; Houston, TX; and Los Angeles, CA. Methods: From November 2011 to October 2012, stool specimens from all patients with AGE for clinician-requested diagnostic testing were stored and shipped to the Centers for Disease Control and Prevention (CDC) for supplemental testing for the presence of norovirus. Outpatient and community- and hospital-acquired inpatient norovirus-associated AGE incidence were calculated using administrative and patient population data from each VA Center. Results: Fifty (4%) of 1,160 stool specimens collected ≤7 days from symptom onset tested positive for norovirus; 6.9% of outpatient (n=203), 6.2% of community-acquired inpatient (n=375), and 2.2% of hospital-acquired inpatient (n=582) samples tested positive for norovirus. Norovirus-positivity followed a seasonal pattern with 33 (66%) of norovirus-positive specimens collected between November 2011 and March 2012. During a one year period, the estimated incidence of community and hospital-acquired norovirus AGE was 200 and 62 cases/ 100,000 patients, respectively. A total of 7 norovirus genotypes were detected of which the majority (74%) was one of the GII.4 variants including GII.4 New Orleans (46%), GII.4 Minerva (14%), and GII.4 Sydney (14%). Five specimens (10%) were GI.6, a typically uncommon genotype that transiently emerged nationwide as a major disease-causing variant during this period. Conclusion: This study demonstrates the incidence of community- and hospital-acquired norovirus AGE among a geographically distributed VA population.
    IDWeek 2014 Meeting of the Infectious Diseases Society of America; 10/2014
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    ABSTRACT: Background: Concerns exist whether monovalent (RV1) and pentavalent (RV5) rotavirus vaccines provide adequate protection against diverse strains and whether vaccine introduction will lead to selective pressure. Methods: We systematically reviewed vaccine effectiveness (VE) studies and classified strains as (1) homotypic: both G- and P-type antigen of the circulating strain were in the vaccine; (2) partially heterotypic: either the G- or P-type antigen of the circulating strain was in the vaccine; and (3) fully heterotypic: neither G- or P-type antigen of the circulating strain was in the vaccine. Some RV5 studies reported VE against the G- and the P-type component separately and could not be discreetly classified into the three categories. To make complete use of the data, we included these strains in our analysis, classifying them either as (1) single antigen (SA) vaccine-type; or (2) SA nonvaccine-type. We estimated pooled odds ratios using random effect regression models, and tested for differences in strain-specific VE. Strain distribution trends were assessed from surveillance reports. Results: In high income countries, RV1 pooled VE (95% CI) was 94% (80-98), 71% (39-86), and 87% (76-93) against homotypic, partially heterotypic, and fully heterotypic strains, respectively. RV5 VE was 83% (78-87), 82% (70-89), 82% (70-89) and 75% (47-88) against homotypic, SA vaccine-type, partially heterotypic, and SA nonvaccine-type strains, respectively. In middle income countries, RV1 pooled VE was 59% (36-73), 72% (58-81), and 47% (28-61) against homotypic, partially, and fully heterotypic strains, respectively. RV5 VE was 70% (58-78) against SA vaccine-type, 37% (10-56) against partially heterotypic strains and 87% (38-97) against SA nonvaccine-type. We found no evidence of a difference in VE for either vaccine in any setting (all p<0.05) Prevalent strains in RV1 countries were G2P[4] (50%) and G1P[8] (22%), compared with G1P[8] (33%) and G2P[4] (30%) in RV5 countries . Sustained predominance of a single strain was not observed. Conclusion: RV1 and RV5 exert similar effectiveness against homotypic and heterotypic strains. We found no evidence for persistence of specific strains indicating vaccine-induced selective pressure.
    IDWeek 2014 Meeting of the Infectious Diseases Society of America; 10/2014
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    ABSTRACT: Background The effectiveness of the rotavirus vaccine under conditions of routine use in an African setting with a high prevalence of HIV infection needs to be established. We assessed the vaccine effectiveness of monovalent human rotavirus vaccine in preventing admission to hospital for acute rotavirus diarrhoea, after its introduction at age 6 and 14 weeks into South Africa's national immunisation programme. Methods This case-control study was done at seven hospitals in South Africa between April 19, 2010, and Oct 31, 2012. The hospitals were located in a range of urban, peri-urban, and rural settings, with varying rates of population HIV infection. Cases were children aged from 18 weeks to 23 months who were age-eligible to have received at least one dose of the human rotavirus vaccine (ie, those born after June 14, 2009) admitted to hospital with laboratory-confirmed acute rotavirus diarrhoea, and the primary control group was children admitted to hospital with diarrhoea testing negative for rotavirus. A second control group comprised children admitted to a subset of three of the seven hospitals with respiratory illness. The primary endpoint was adjusted vaccine effectiveness (1 – adjusted odds ratio × 100%) in children aged from 18 weeks to 23 months and was calculated by unconditional logistic regression. This study is registered on the South African National Clinical Trial Register, number DOH-27-0512-3247. Findings Of 540 rotavirus-positive cases, 278 children (52%) received two doses, 126 (23%) one dose, and 136 (25%) no doses of human rotavirus vaccine, compared with 1434 rotavirus-negative controls of whom 856 (60%) received two doses, 334 (23%) one dose, and 244 (17%) no doses. Adjusted vaccine effectiveness using rotavirus-negative controls was 57% (95% CI 40–68) for two doses and 40% (16–57) for one dose; estimates were similar when respiratory controls were used as the control group. Adjusted vaccine effectiveness for two doses was similar between age groups 18 weeks–11 months (54%, 95% CI 32–68) and 12–23 months (61%, 35–77), and was similar in HIV-exposed-uninfected (64%, 95% CI 34–80) and HIV-unexposed-uninfected children (54%, 31–69). Interpretation Human rotavirus vaccine provided sustained protection against admission to hospital for acute rotavirus diarrhoea during the first and second years of life. This finding is encouraging and establishes the public health value of rotavirus vaccine in an African setting, especially as rotavirus vaccines are introduced into an increasing number of African countries. Funding GAVI Alliance (with support from PATH).
    The Lancet Infectious Diseases 10/2014; 14(11). DOI:10.1016/S1473-3099(14)70940-5 · 19.45 Impact Factor

Publication Stats

15k Citations
2,633.18 Total Impact Points

Institutions

  • 1998–2015
    • Centers for Disease Control and Prevention
      • • Division of Viral Diseases
      • • National Center for Immunization and Respiratory Diseases
      • • National Center for Emerging and Zoonotic Infectious Diseases
      Атланта, Michigan, United States
    • University of Maryland, Baltimore
      • Department of Pediatrics
      Baltimore, Maryland, United States
  • 2012
    • University of Illinois, Urbana-Champaign
      Urbana, Illinois, United States
    • PATH
      Seattle, Washington, United States
  • 2011
    • Center for Adolescent Health and the Law
      North Carolina, United States
    • National Institute of Infectious Diseases, Tokyo
      Edo, Tōkyō, Japan
  • 2009
    • National Autonomous University of Nicaragua, Managua
      Μανάγκουα, Managua, Nicaragua
    • Malawi Centers of Disease Control and Prevention
      Lilongwe, Central Region, Malawi
    • University of Melbourne
      • Department of Paediatrics
      Melbourne, Victoria, Australia
  • 1998–2009
    • Emory University
      • • Centers for Disease Control and Prevention
      • • Department of Global Health
      • • Department of Pediatrics
      Atlanta, Georgia, United States
  • 2008
    • Queen Mary Hospital
      Hong Kong, Hong Kong
  • 2005
    • The Chinese University of Hong Kong
      Hong Kong, Hong Kong
    • Stanford University
      Palo Alto, California, United States
    • Cincinnati Children's Hospital Medical Center
      • Division of Infectious Diseases
      Cincinnati, Ohio, United States
  • 2000–2005
    • National Institute of Allergy and Infectious Diseases
      Maryland, United States
    • National Institute of Allergy and Infectious Disease
      Atlanta, Georgia, United States
  • 2004
    • Maryland Department of Health and Mental Hygiene
      Baltimore, Maryland, United States
  • 2001
    • U.S. Department of Health and Human Services
      • Centers for Disease Control and Prevention (CDC)
      Washington, D. C., DC, United States
  • 1999
    • Yale University
      New Haven, Connecticut, United States
    • The University of Arizona
      Tucson, Arizona, United States
    • Alpert Medical School - Brown University
      Providence, Rhode Island, United States