who-coordinated global rotavirus and pediatric diarrhea
TRANSCRIPT
Adam L. CohenThirteenth International Rotavirus Symposium
WHO-Coordinated Global Rotavirus and Pediatric Diarrhea Surveillance
Minsk, Belarus | 29 August 2018
Why do countries conduct vaccine-preventable disease surveillance?
Pre-vaccine introduction
• To describe disease burdento make decisions about vaccine introduction
Impact of introduction
• To monitor trends to show impact and cost-effectiveness of vaccine and vaccination program
Long-term monitoring
• To monitor changes in disease after introduction
• To document control, elimination, and eradication
• Identify outbreaks for immediate action for effective reactive vaccination campaigns
• Components of surveillance can be leveraged to monitor other VPDs and other diseases without vaccines
• Identify unreached populations not getting vaccinated for targeted delivery strategies
Acrossall
phases
Ref: Cohen, A. et al. Using surveillance and economic data to make informed decisions about rotavirus vaccine introduction. Vaccine. 2018 Aug 18.
Why do countries conduct vaccine-preventable disease surveillance?
Pre-vaccine introduction
• To describe disease burdento make decisions about vaccine introduction
Impact of introduction
• To monitor trends to show impact and cost-effectiveness of vaccine and vaccination program
Long-term monitoring
• To monitor changes in disease after introduction
• To document control, elimination, and eradication
• Identify outbreaks for immediate action for effective reactive vaccination campaigns
• Components of surveillance can be leveraged to monitor other VPDs and other diseases without vaccines
• Identify unreached populations not getting vaccinated for targeted delivery strategies
Acrossall
phases
Ref: Cohen, A. et al. Using surveillance and economic data to make informed decisions about rotavirus vaccine introduction. Vaccine. 2018 Aug 18.
Country commitment
Nationwide, case-based with laboratory confirmation of every case
Nationwide, aggregate with laboratory confirmation of outbreaks
Sentinel, case-based with laboratory confirmation of every case
Other (e.g. VPDs have different minimum standard of surveillance based on context)
Surveillance commitment in every country
• Measles• Poliomyelitis - -
• Neonatal Tetanus (no lab confirmation)
Surveillance commitment varies by country
• Diphtheria• Meningococcus• Rubella
• Hepatitis A• Hepatitis B• Mumps
• Congenital rubella syndrome
• H. Influenzae• Influenza• Japanese
encephalitis• Pertussis
Pneumococcus• Rotavirus• Typhoid
• Cholera (event-based)• HPV (surveillance not
recommended)• Non-neonatal Tetanus
(no lab confirmation)• Varicella (no lab
confirmation)• Yellow fever (pending)
Summary of updated WHO minimum recommended VPD surveillance standards
http://www.who.int/immunization/monitoring_surveillance/burden/vpd/standards/en/
Country commitment
Nationwide, case-based with laboratory confirmation of every case
Nationwide, aggregate with laboratory confirmation of outbreaks
Sentinel, case-based with laboratory confirmation of every case
Other (e.g. VPDs have different minimum standard of surveillance based on context)
Surveillance commitment in every country
• Measles• Poliomyelitis - -
• Neonatal Tetanus (no lab confirmation)
Surveillance commitment varies by country
• Diphtheria• Meningococcus• Rubella
• Hepatitis A• Hepatitis B• Mumps
• Congenital rubella syndrome
• H. Influenzae• Influenza• Japanese
encephalitis• Pertussis
Pneumococcus• Rotavirus• Typhoid
• Cholera (event-based)• HPV (surveillance not
recommended)• Non-neonatal Tetanus
(no lab confirmation)• Varicella (no lab
confirmation)• Yellow fever (pending)
Summary of updated WHO minimum recommended VPD surveillance standards
http://www.who.int/immunization/monitoring_surveillance/burden/vpd/standards/en/
Countries that conducted rotavirus surveillance in 2017
WHO Global Rotavirus Surveillance and Laboratory Network (GRSN and GRLN), 2017
WHO Global Invasive Bacterial Vaccine Preventable Disease and Rotavirus Surveillance Network Bulletin, July 2018, http://www.who.int/immunization/monitoring_surveillance/resources/NUVI/en/
Rotavirus positivity among children enrolled in GRSN, by WHO Region, 2017
WHO Global Invasive Bacterial Vaccine Preventable Disease and Rotavirus Surveillance Network Bulletin, July 2018, http://www.who.int/immunization/monitoring_surveillance/resources/NUVI/en/
Rotavirus positivity among children enrolled in GRSN, by Country, 2017
Trends in rotavirus genotype distribution globally, 2010-2016
Nakamura, et al. WHO-coordinated Global Rotavirus Laboratory Network: A Platform to Leverage Pediatric Diarrheal Disease Surveillance. International Rotavirus Symposium, Minsk. 2018.
403,140 children hospitalized with AGE from 349 sites in 82 countries
Global rotavirus vaccine impact using Global Rotavirus Surveillance Network, 2008-2016
Aliabadi, et. al. Unpublished
403,140 children hospitalized with AGE from 349 sites in 82 countries
Global rotavirus vaccine impact using Global Rotavirus Surveillance Network, 2008-2016
RVV
intr
o.
Aliabadi, et. al. Unpublished
403,140 children hospitalized with AGE from 349 sites in 82 countries
Global rotavirus vaccine impact using Global Rotavirus Surveillance Network, 2008-2016
RVV
intr
o.
Aliabadi, et. al. Unpublished
403,140 children hospitalized with AGE from 349 sites in 82 countries
Global rotavirus vaccine impact using Global Rotavirus Surveillance Network, 2008-2016
RVV
intr
o.
Rotavirus prevalence decreased by nearly 40% following vaccine introduction
Aliabadi, et. al. Unpublished
Global Rotavirus Surveillance
Network (GRSN)
Pilot TAC card testing in 4 Regional
Reference Laboratories
Global PediatricDiarrhea
Surveillance (GPDS)
Leveraging GRSN to understand other pediatric diarrheal diseases
16
Countries with Sites Participating in GPDS
Acute(<14 days)
Persistent(≥14 days)
Watery
Bloody
• Global Rotavirus Surveillance Network (GRSN) Case Definition: Acute (<14 days) watery diarrhea (AWD)
• Global Pediatric Diarrhea Surveillance (GPDS) Expanded Case Definition: All pediatric diarrhea regardless of duration or presence of blood in stool
• Acute (<14 days) and persistent (≥14 days) diarrhea
• Watery and bloody diarrhea
GPDS Expanded Case Definition
AWD (GRSN Case Definition)
All diarrhea (GPDS Case Definition)
• 100 specimens per year from each of 37 participating sites in 32 countries
o Two countries starting 2019
o Tested by TAC in Regional Reference Laboratories (3-6 countries per RRL)
• Only cases, no controls: Pathogen quantities in each diarrheal sample from GPDS combined with strength of association (odds ratio) between pathogen quantity and diarrhea based on modeled association with case status from GEMS case-control study (Liu J and Platts-Mills J, et al, Lancet 2016)
GPDS Methods
1
.8
.5
.3
0
1 2 3 4 5 6 7 8
242322212019181716151413121110
987654321
GI pathogen assay Clinical Sample Control Manufacture Positive Control
PortL R
Rotavirus Rotavirus (CDC)Rotarix_NSP2 & RotaTeq_VP6 VP7_G1VP4_P[4] VP7_G2VP4_P[6] VP7_G3 & G4VP4_P[8] VP7_G9VP4_P[10] & P[11] VP7_G8 & G10VP4_P[9] & Ebola VP7_G12MS2 MS2Astrovirus Norovirus GI & GII
Sapovirus Norovirus GII.4 & GI.1Shigella/EIEC (ipaH) Adenovirus 40/41 & Pan
S. flexneri (non 6) & S. flexneri 6 S. sonneiS. Other (boydii, dysen, flex6) S. dysen Type 1 & M.tb18S AeromonasB.fragilis & C.difficile Campylobacter jejuni/coliSalmonella V. choleraeEAEC_aaiC & aatA EPEC_eae & bfpAETEC_STh & STp ETEC_LTETEC_CFA/I & CS1 ETEC_CS2 & CS3ETEC_CS5 & CS6 STEC_stx1 & stx2PhHV PhHVCyclospora & Isospora E.bieneusi & E.intestinalisCryptosporidium & E.histolytica Giardia & StrongyloidesAncyclostoma & Necator Ascaris & Trichuris
Global Pediatric Diarrhea Surveillance Taqman Array Card (TAC)
Clinical Presentation of Pediatric Diarrhea (GPDS), 2017-present--Preliminary results
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
WPR
SEAR
EUR
AMR
AFR
Global
Acute watery Acute bloody Persistent watery Persistent bloody
Attributable fraction of pediatric diarrhea etiology, GPDS, Global, 2017--Preliminary results
0%
5%
10%
15%
20%
25%
30%
35%
Attri
buta
ble
Frac
tion
(95%
CI)
06/09/2018 |
Attributable fraction of pedatric diarrhea etiology, GPDS, by Syndrome, 2017--Preliminary results
0%
5%
10%
15%
20%
25%
30%
35%
Attr
ibut
able
Fra
ctio
n (9
5% C
I)
Watery
Bloody
Attributable fraction of pediatric diarrhea etiology, GPDS, by Age group, 2017--Preliminary results
0%
5%
10%
15%
20%
25%
30%
35%
Attr
ibut
able
Fra
ctio
n (9
5% C
I)
Infants (<1 y)
Older (1-<5y)
• Rotavirus and pediatric diarrhea surveillance is critical to generate date for use at country, regional and global levels
• Should be responsive to the needs of country for national vaccine policy (e.g., rotavirus vaccine introduction and impact)
• Provides data for global policy (e.g., enteric vaccines in development such as Shigella, ETEC, and norovirus)
• Continue GPDS for 2 full calendar years of surveillance and consider long-term
• First full year of data available early 2019
• Maintain sustainable Global Rotavirus and Pediatric Diarrhea Surveillance Network through capacity building and country and external funding
Summary
Acknowledgements
• Sentinel surveillance hospitals• Ministries of Health• WHO Country and Regional offices• National, Regional, and Global Reference
laboratories• Partners (U.S. CDC, Gavi, BMGF,
University of Virginia)
