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The democratic virus and its major weakness – vaccines

June 15, 2018 by PATH

A child in Zambia receives the rotavirus vaccine. Photo: PATH/Gareth Bentley

After her children struggled with diarrheal disease, Teresa was determined to get one-month-old Vusi vaccinated as soon as she heard about the availability of rotavirus vaccines. Photo: PATH/Gareth Bentley.

Rotavirus is the leading cause of severe and fatal diarrhea in young children worldwide. Vaccines are its weakness.

A television. A toilet. A sofa. Conveniences many mothers in Zambia don’t have. Teresa knows she’s fortunate to have them, yet these small luxuries couldn’t protect her child. In 2011, Teresa rushed her firstborn to the hospital, too many times to count. Severe diarrhea, again and again. It seemed there was nothing she could do. Sometimes she wonders: Was it my fault he almost died?

Two years later, she gives birth to her second child. This time, things are different. In a small clinic, she cradles her one-month old—a boy named Vusi. Nearby, a nurse uncaps a small vial filled with a few drops of rotavirus vaccine.

Vusi cries as the nurse puts the liquid into his mouth, but Teresa smiles.

'The democratic virus'

Diarrhea is a killer.

We’re not talking about the loose stools that you might get after eating too much fast food. We’re talking about diarrheal disease: also known as “stomach flu” or gastroenteritis. It’s caused by an infection that rapidly dehydrates your body, causing fever, vomiting, and severe diarrhea. While this type of illness may only be a short-lived discomfort in adults, in young children like Teresa’s, diarrhea can be a death sentence.

Diarrheal disease can be caused by a variety of bacteria, viruses, and parasites, many of which have become household names due to outbreaks (think E. coli or norovirus). But the number one culprit behind the daily death toll of diarrhea among children worldwide is one you may not have heard of: a highly contagious virus called rotavirus.

Rotavirus, named for its wheel-like shape, is as common as it is deadly. It’s often called “the democratic virus” because every child in every country, rich or poor, regardless of access to safe water and sanitation, is at risk of infection. However, the vast majority of rotavirus-related deaths occur in low-income countries in Africa and Asia, where access to lifesaving care like IV fluids can be limited or unavailable. Rotavirus is resistant to traditional diarrhea prevention strategies like handwashing and clean water supplies.

This makes this bug tougher to beat than most, but rotavirus has an Achilles’ heel: vaccines.

Vaccination is the best way to prevent rotavirus, and we’ve been on the front lines of efforts to develop, accelerate, and support rotavirus vaccines for over 15 years.

Setting the stage for rotavirus vaccines

In 2003, two vaccines against rotavirus were getting ready to enter the market. However, surprisingly few people knew the virus’ name, let alone that it was the leading cause of severe diarrheal disease. “We’ve never heard of it,” ministers of health would say when PATH and our partners began meeting with them to spread the word about the virus and the new vaccines.

Diarrhea has many different causes, and we realized that while a vaccine against rotavirus would be a key step toward protection, it would need to be part of an integrated approach to diarrheal disease control. We listened closely to public health officials, partnering with them to prioritize their countries’ needs and opportunities for integrated control of diarrheal disease with vaccines alongside oral rehydration solution (ORS), zinc, exclusive breastfeeding and nutrition, and improvements in water, sanitation, and hygiene. And as new data emerged about the burden of rotavirus and the cost-effectiveness of vaccines, the interest of country leaders in these vaccines grew.

The vaccines were finally approved in 2006. That year, with PATH’s help, Nicaragua became the first low-income country to adopt rotavirus vaccines—the same year rotavirus vaccines were introduced in the United States. Within two years, massive vaccination campaigns in Nicaragua led to 60 percent fewer severe cases of rotavirus. Other countries in the Americas and Europe soon followed.

“ Countries that have introduced the vaccines have seen dramatic reductions in rotavirus deaths and hospitalizations. ”

In June 2009, informed by the results of pivotal vaccine effectiveness studies in Africa and Asia coordinated by PATH and our partners, the World Health Organization recommended that all national immunization programs worldwide should include rotavirus vaccines. South Africa introduced rotavirus vaccines that year, and uptake across Africa accelerated over the next five years. Zambia introduced rotavirus vaccines in 2013, allowing Vusi to be vaccinated.

As of mid-2018, over 95 countries worldwide have introduced rotavirus vaccines, including a majority of countries in Africa. Countries that have introduced the vaccines have seen dramatic reductions in rotavirus deaths and hospitalizations.

But the work to stop this leading child killer isn’t over yet. Over half of the world’s children still don’t have access to rotavirus vaccines.

More vaccines, more supply, more impact

While the currently available rotavirus vaccines are effective and safe, they’re not perfectly suited for the low-income countries that need them most. They’re expensive and don’t always work as well in low-income countries as they do in high-income countries.

“ The work to stop this leading child killer isn’t over yet. Over half of the world’s children still don’t have access to rotavirus vaccines. ”

So while we’ve worked to support country introductions with currently available vaccines, we’re also simultaneously supporting the development of new rotavirus vaccines that are more affordable and may be more sustainable or beneficial for some countries in the long run. For example, PATH supported the development of two Indian-made vaccines: ROTAVAC®, which is just US$1 per dose, and ROTASIIL®, which is heat-resistant. Both have been introduced in India’s national immunization program.

From our perspective, the more options, the better. By helping make more rotavirus vaccines available for countries to choose from, we can increase access, improve supply, reduce costs, and ultimately save more lives from this preventable disease.

Democratic, but unjust

A “democratic” virus, yes, but also vicious and unjust. Rotavirus affects everyone, but only kills those who are most vulnerable.

Luckily, we know how to take it down.

PATH and our partners’ longtime work in rotavirus vaccines has led to some exciting milestones, from the first introduction in Nicaragua, to introductions across Africa and now in Asia, to the prequalification of new vaccines. But we know there’s more work ahead.

Will you join us?

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