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  • The study by Tripathy and

    2019-04-28

    The study by Tripathy and colleagues yet again makes a convincing case for scaling up of participatory women\'s groups for learning and action to improve newborn survival in contextually comparable rural settings. Countries that do not have existing village-level functionaries who could act as facilitators for women\'s group meetings would need to recruit such workers. The investment for capacity, tools, compensation, and supervision will also have to be made. It would be wise to undertake early scale-up of this intervention within national programmes in conjunction with implementation research. This will enable systematic learning and course correction as the coverage is expanded. Implementation research catalyses effective factor xa inhibitors of new interventions into the health systems, and increases the likelihood of their successful uptake in varied settings.
    The study by Fidele Ngabo and colleagues in shows the feasibility of the successful introduction and large effect of rotavirus vaccination in Rwanda. The findings are a tribute not only to rotavirus vaccination but also to the RotaTeq (so-called pentavalent or RV5) vaccine because Rwanda has used this vaccine exclusively in its immunisation programme. Several African countries have introduced rotavirus vaccination using the human rotavirus vaccine Rotarix and good effectiveness has been reported from South Africa and Malawi. The real-life effectiveness of RotaTeq in Rwanda was recorded in several ways and is convincing. After the introduction of rotavirus vaccination in 2012, admittance to hospital for gastroenteritis decreased by 49% in 2013, and 48% in 2014, and admittance to hospital for rotavirus in the hospitals doing specific rotavirus diagnosis decreased by 61% and 70% in the same period. The effectiveness is actually in line with the available prelicensure efficacy data for RotaTeq in Kenya (83%) and Ghana (65%) against severe rotavirus gastroenteritis severity score (the Vesikari score) of 11/20. It is impressive that, according to the report of Ngabo and colleagues, Rwanda has reached a coverage rate of 98–99% for rotavirus vaccination. Although it does not specify whether this meant all three doses, the study shows that RotaTeq vaccination is compatible with the Expanded Programme on Immunization (EPI) dosing at 6, 10, and 14 weeks of age and that a three-dose vaccine (and not only two-dose Rotarix) can successfully be given in Africa. Three doses might be better than two because durable immunity against rotavirus depends on the number of hits, whether vaccination or natural infection, although the two-dose Rotarix has also shown good protection in Africa. The report contains no information about rotavirus serotypes in Rwanda. This is not that important though because for practical purposes surveillance of rotavirus serotypes is becoming obsolete as it has been convincingly shown that the efficacy and effectiveness of rotavirus vaccines against severe rotavirus gastroenteritis are not serotype-specific. Thus, the pentavalent and monovalent vaccines are at the same start line. As an example, the 49% efficacy of Rotarix in Malawi was the same against various rotavirus G-types that were recorded during the trial. If the performance of rotavirus vaccines in Africa is not as good as in developed countries, it is not because there are more diverse rotavirus serotypes circulating in Africa. Although the effectiveness of rotavirus vaccine in Rwanda is high and is promising, the effectiveness is still less than in developed countries. For example, in Finland, with equally high coverage, the effect of rotavirus vaccination has been an 88% reduction of admittances to hospital for rotavirus gastroenteritis, with most of the remaining cases occurring in older children who have been too old to be vaccinated in the programme, and very few breakthrough cases of severe rotavirus gastroenteritis in vaccinated children, and even those mostly in partially vaccinated children. Such information from Rwanda (and other African countries) is missing, and future studies should address the effectiveness of RotaTeq vaccine after complete and incomplete series of vaccinations.