Nicaragua:Early Experience with Routine Use

of Rotavirus VaccinesDr. Juan Jose Amador – PATH Nicaragua

jamador@path.org

8th International Rotavirus Symposium, Istanbul, Turkey

3-4 June 2008

Nicaragua

11141051 1034

1301 1301

1439

1545

1634

849

612 622

492536

443 461 449

245204 191

145 17498 122 90

0

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Acute Diarrhoeal Disease Mortality in Children < 1 Year of AgeNicaragua, 1983-2006

Source: SINEVI (National Statistic System for Mortality)

CholeraeIntroduction ToLatin America

Last Case of Cholerae

Timeline of Events Related to the Rotavirus Vaccination

2006 2007

LaunchOct. 27th

2006

NationalPediatricsConferenceAug. 19th

AMNCongress Aug. 31st

ClintonGlobal

Initiative Sept. 22nd

NationalTraining

UAM Auditorium

Strengthening of the Epidemiological Surveillance

VaccinationStartsEntire

Country

2nd DoseApplied

3rd DoseApplied

Merck and MoH

HEODRASurveillance

Surveillance and

EffectivenessStudy

MoH-PAHO PATH-CDCMay 14th

HurricaneFelix

Beginning ofNegotiations

with manufacturers

DecisionMade:

RotaTeq

NCIP

First TAGMeeting July 24th

AllianceMoH, PATH

NGO New MoHAuthorities

2005

2005 Epidemics

CDCPAHOMoH

Research

PATHVisit to

PromoteRotavirusVaccine

NEJMPublications NCIP

Effectiveness 5 aditional hospitals

TAGTelecom meeting

Merck visitPAHO/CDC visit

The Ministry of Health of NicaraguaDecided to Introduce the RotaTeq VaccinesTo the National Scheme of Immunization

On May 2006

August 17th 2006 – UAM Workshop

LAUNCHOCTOBER 27TH 2006

LAUNCHOCTOBER 27TH 2006

National Campaign April to May 2007 Routine Immunizations 2007

New Government strong support

• 5 November 2006 elections resulted in President Daniel Ortega government

• 10 January 2007, new Minister of Health Dra. Maritza Cuan takes office

• 02 November 2007, New Minister of Health Dr. Guillermo González

• High promotion of Community Participation in Health

Rotavirus Vaccination in NicaraguaOctober 2006 – April 2008

Coverage of the First, Second and Third Doses of Rotavirus Vaccine Children Under 1 Year of Age, Nicaragua, 2007 to 03/2008

*

%

* Not included data of April 2008

Coverage of the First, Second and Third Doses of Rotavirus Vaccine According to SILAIS of the First Cohort of Children Under 1 Year of Age

Nicaragua 2007

0

20

40

60

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120

Carazo

Boaco

Madriz

N. Sego

via

Masay

aEste

lí

Granad

a

Chinan

dega

León

R.S.Juan

Rivas

Managu

a

Mataga

lpa

Jinote

ga

Chonta

lesRAAS

RAAN

Porc

enta

je R1

R2

R3%

Incidence of Intussusception for children < 1 Year of AgeNicaragua 2000-2007

Rate for 10 000 Rotavirus Vaccination

Start (Nov. 06)

AGE -- number of consultations at Primary Health Care Services, Nicaragua 1993-2007

Deaths Caused by AGE in Children <1 and 1 to 4 Years of Age, Nicaragua 2000-2007

Rotavirus Vaccination

Start (Nov.06)

Mortality Rate by Acute Diarrheal Diseases in Children Under 5, Nicaragua 2000-2005 and 2007

Rate x 100,000

Source: SINEVI (National Statistic System for Mortality)

Surveillance and Effectiveness Evaluation

• Merck, MINSA, UNAN-Leon: 6 sentinel hospitals• National Children Hospital Manuel de Jesus Rivera - La Mascota • The German-Nicaraguan Hospital in Managua, • Hospital Oscar Danilo Rosales Arguello (HEODRA) in León, • Maternity and Infant Hospital in Chinandega, • Hospital San Juan de Dios in Estelí• Hospital Friendship Japan-Nicaragua in Granada.

• PAHO/CDC/PATH/MoH: 4 sentinel hospitals• Hospital Fernando Vélez Paiz in Managua, • Santiago Regional Hospital in Jinotepe, • Hospital Humberto Alvarado in Masaya • Regional Hospital in Matagalpa.

Lessons Learned

• Strong collaboration

– Merck & Co., Inc.– PATH, PAHO, CDC,

UNICEF

– MoH, National NGOs

• Important issues:

– Planning and training

– Vaccine effectiveness

– Cold chain evaluation

– Media communication and Health Education

– Community Participation

• The vaccine has been well accepted by the medical and scientific community in the country, showing a good safety profile and minimum secondary effects.

• Health personnel were trained in the application of the vaccine in workshops implemented at different levels such as national, provinces, municipal, and local training sessions.

• Cold chain capacity adequate, but it was necessary to increase the frequency of vaccine deliveries (roughly double).

• Health professionals found vaccine convenient because it is orally-administered and does not require reconstitution.

• Occasionally, personnel did not follow technical norms by failing to introduce the applicator of the oral vaccine into the child’s mouth/cheek.

Summary

• AGE is a leading cause of <5 morbidity and mortality in Nicaragua

• Rotavirus was the cause of a large diarrheal outbreak in early 2005

• National, regional (PAHO) and international (WHO) policy supported the adoption of rotavirus vaccine

• Merck’s RotaTeq was introduced on 27 October 2006

• RotaTeq coverage is high, and improving as Rota1-Rota2-Rota3 drop out declines

• Surveillance is underway to document the impact of rotavirus vaccination and vaccine effectiveness (2009)

• Political commitment and broad collaboration is important for a successful vaccine introduction

THANKS