Rotavirus Vaccines and Vaccination in Latin America

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Rotavirus Vaccines and Vaccination in Latin America Rotavirus vaccines and vaccination in Latin America Alexandre C. Linhares1 and Joseph S. Bresee2 ABSTRACT Worldwide, rotaviruses account for more than 125 million cases of infantile gastroenteritis and nearly 1 million deaths per year, mainly in developing countries. Rather than other con- trol measures, vaccination is most likely to have a major impact on rotavirus disease incidence. The peak incidence of rotavirus diarrhea occurs between 6 and 24 months of age. In develop- ing countries, however, cases are not uncommon among children younger than 6 months. G serotypes 1 to 4 are responsible for most disease, but there are indications that in Brazil that G type 5 is of emerging epidemiological importance. Both homotypic and heterotypic responses are elicited during natural rotavirus infection, and the immunological response at the intesti- nal mucosal surface is probably the more consistent predictor of clinical immunity. With the primary objective of protecting children against life-threatening dehydrating diar- rhea, many approaches to rotavirus vaccine development have been attempted. One vaccine, the tetravalent rhesus-human reassortant rotavirus vaccine (RRV-TV), was given licensing approval in the United States of America, introduced to the market, and later withdrawn. A number of studies have found better efficacy of RRV-TV in developed countries than in developing ones. Field trials with a 4 ϫ 104 plaque-forming units (PFU) preparation of RRV- TV have been carried out in two countries in Latin America, Brazil and Peru. Those trials yielded protective efficacy rates against all rotavirus diarrhea ranging from 18% to 35%. Data from a large catchment trial in Venezuela with a higher RRV-TV dose, of 4 ϫ 105 PFU/dose, indicated an efficacy rate of 48% against all rotavirus diarrhea and 88% against severe ro- tavirus diarrhea. It appears that breast-feeding does not compromise the efficacy of RRV-TV if three doses of the vaccine are administered. Similarly, possible interference of oral poliovirus vaccine with the “take” of the rotavirus vaccine can be overcome by giving three doses of the rotavirus vaccine or by using a higher-titer formulation of it. Wild enteroviruses, however, may cause primary rotavirus vaccine failure in developing countries. Studies in Peru with RRV-TV have shown a trend towards higher vaccine efficacy rates against “pure” (rotavirus- only) diarrheal episodes. Economic analyses made in the United States indicate that a vaccine that costs less than US$ 9 per dose would lead to a net savings in medical costs. To date, how- ever, cost-benefit studies have not been done in developing countries. In the future, it is possi- ble that some Latin American countries might adapt their polio production facilities to the preparation of rotavirus vaccines for human use. A year after RRV-TV was licensed for vaccination of infants in the United States, the oc- currence of intussusception as an adverse event led to the vaccine’s withdrawal from the mar- ket. The implications of that action, particularly for Latin America, will be addressed in this article, including the need to explore alternative rotavirus candidate vaccines, particularly through the conduct of parallel clinical trials in both developed and developing countries. 1 Fundação Nacional de Saúde, Instituto Evandro gas, Virology Section, Av. Almirante Barroso, 492, 2 United States, Centers for Disease Control and Chagas, Virology Section, Belém, Pará, Brasil; Send 66.090-000, Belém, Pará, Brasil; telephone: (091) Prevention, Division of Viral and Rickettsial Dis- correspondence to: Alexandre C. Linhares, Fun- 2114403; fax: (091) 2261284; e-mail: linhares@ eases, Respiratory and Enteric Virus Branch, At- dação Nacional de Saúde, Instituto Evandro Cha- supridad.com.br lanta, Georgia, United States of America. Rev Panam Salud Publica/Pan Am J Public Health 8(5), 2000 305 Acute gastroenteritis is a leading as rotaviruses, enteric adenoviruses, will briefly discuss available infor- cause of morbidity and mortality in in- astroviruses, and Norwalk and/or mation on rotavirus structure and fancy and childhood throughout the antigenically related agents (15). It has antigenic composition, epidemiology, world, especially in developing coun- been estimated that viral agents ac- and immunity. We will especially em- tries. Each year diarrheal diseases count for a minimum of 30% of docu- phasize the epidemiological features cause 744 million to one billion cases mented cases of infectious diarrhea in of rotavirus infection in Latin Ameri- of diarrhea in Africa, Asia, and Latin the United States of America (16). can countries. America in children under 5 years of Since their first detection by Bishop age. Of these children, it is estimated et al. (17) in Melbourne, Australia, ro- that 2.4–3.3 million of them die per taviruses have been clearly established GENERAL INFORMATION ON year, corresponding to some 6 600 to as the most common cause of severe, ROTAVIRUS INFECTION 9 000 deaths per day (1–3). An addi- dehydrating gastroenteritis in infants tional hazard in developing countries and young children in both industrial- Structure and is that malnutrition makes children ized and developing countries (18, 19). antigenic characterization more prone to severe disease and, con- It has been estimated that rotaviruses versely, repeated episodes of diarrhea each year worldwide are associated The rotaviruses are classified within may lead to malnutrition (1). with more than 125 million cases of in- a specific genus of the family Reo- In Latin America the incidence rates fantile gastroenteritis and cause a min- viridae. The complete virus particle of diarrheal disease among infants and imum of 418 000 to 520 000 deaths, is often described as smooth, mea- young children vary widely between 85% of which occur in low-income sures about 70 nm in diameter, and different regions and localities, accord- countries (20, 21). An effective vaccine is composed of three protein shells ing to prospective community-based could prevent as many as 326 000 of surrounding the genome. This triple- studies (1). In the poorest periurban these deaths each year (20, 21). layered structure possesses cap- communities of Peru and Brazil, the The similar incidence of the illness someres radiating from the inner to average annual number of diarrheal in both industrialized and developing the outer capsid, like the spokes of a episodes per child under 2 years of age countries suggests that the problem wheel (rota, Latin for wheel) (24). In- reaches 10 or more, while the inci- will not be controlled by merely im- complete (or rough) “single-shelled” dence rate may be as low as 0.7 per proving the water supply, sanitation, particles lacking the outer capsid are child per year among infants (0–1 year or hygiene practices, and that an effec- also commonly found in stool samples old) in Costa Rica (4–7). tive vaccine is required (22, 23). De and tissue culture supernatants. The Estimates for mortality indicate that Zoysa and Feachem (22) calculated viral genome, located within the core, the annual number of deaths caused that the administration of an effective consists of double-stranded RNA that by diarrhea among infants less than 1 rotavirus vaccine within the first 6 can be separated by gel electrophore- year of age also varies widely from re- months of life might prevent at least sis into 11 discrete segments, or genes. gion to region, ranging from 4.5 per 16% of the diarrhea deaths that occur Each of these genes encodes a single 1 000 live births to 21.8 per 1 000 (8, 9). among children under 5 years of age. protein, except gene 11, which seems Nevertheless, data that the Pan Amer- These figures fully justify current glo- to encode two distinct polypeptides ican Health Organization (PAHO) bal efforts directed towards the devel- (25). The outermost layer of the double gathered from 21 countries indicate opment of a vaccine targeted for use in capsid is composed of two surface pro- that the overall mortality from diar- early childhood. Rather than prevent- teins, VP7 and VP4. VP7 is a glycopro- rheal disease in Latin America has de- ing rotavirus infection or mild illness, tein coded by gene 7, 8, or 9, and VP4 clined considerably over the past two the primary goal of rotavirus vaccine is a protease-dependent protein coded decades (10–12). Worldwide observa- strategies would be to protect against by gene 4. These two surface proteins tions suggest that several factors may severe diarrhea that might lead to de- independently induce neutralizing an- have contributed to this reduction, hydration and death. tibodies (19, 26, 27). Specific antibody such as instruction in the correct case This review will focus mainly on the response to these proteins has been management of acute watery diarrhea, current status of rotavirus candidate demonstrated after natural rotavirus particularly at health care centers; the vaccines and the prospect of their fu- infection (28) and also following ad- encouragement of breast-feeding; and ture use in public health programs in ministration of candidate vaccines of improvements in measles immuniza- Latin America, including as a result of animal origin (29). tion coverage (1, 13, 14). the introduction of one rotavirus vac- Of particular interest is sero- During these past two decades, the cine to the market and its subsequent response to VP4 following the natural spectrum of enteropathogens known withdrawal following the occurrence infection of humans. That is because to cause diarrhea has increased, pri- of intussusception among some vacci- antibodies to this protein are known marily through the identification of nated infants. To provide background to broadly react across different sero- a number of novel viral agents, such for the main subject of this report we types (30, 31). Cryoelectron micro- 306 Linhares and Bresee • Rotavirus vaccines and vaccination in Latin America scopy studies using computer-assisted serotypes 1 through 4 are recognized to arrheal episodes occurring in this age image enhancement have shown that be globally most common.
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