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Reduction in rotavirus disease due to the infant immunisation programme in England; evidence from national surveillance

J Infect. 2015;71(1):128-31

In this journal, Glass and colleagues recently reviewed the impact of rotavirus vaccines in a number of high and middle income countries. 1 The impact of rotavirus vaccination in these countries has been remarkable, both in terms of reductions in laboratory-confirmed rotavirus infections, and declines in hospitalisations for rotavirus diarrhoea. 1 We would like to add to this body of evidence by reporting preliminary findings from England where rotavirus vaccination was recently introduced.

Rotavirus gastroenteritis in England is seasonal, occurring mainly between January and March, 2 and is responsible for an estimated 130,000 General Practitioner (GP) visits and 13,000 hospitalisations every year in children younger than 5 years. 3 On 01 July 2013, a two-dose, oral rotavirus vaccine, Rotarix®, was introduced into the national infant immunisation programme. 4 On-going real-time national surveillance during the subsequent rotavirus season (January 2014 to March 2014) indicated an unprecedented decline in the number of laboratory-confirmed rotavirus infections, which has been attributed to the immunisation programme ( Supplementary Figure ). 4 The Netherlands, however, reported an unexpected 58% decrease in rotavirus detections in children under 5 year olds during 2013/14 compared to previous years, with near-complete absence of winter excess in cases. 5 The Netherlands does not have a national rotavirus immunisation programme and there have been no changes in diagnostic guidelines or reimbursement policy that might have impacted rotavirus testing practices. The authors speculate mild winter, the relatively high rotavirus season in the previous year, low birth-rate and rotavirus immunisation programmes in the neighbouring countries as potential contributing mechanisms. We, therefore, further analysed data from our surveillance systems to determine whether the observed decrease was genuinely attributable to the national immunisation programme.

Sentinel surveillance for the first cohort of vaccine-eligible children using monthly coverage data from 84% to 91% of all GP practices in England during February to September 2014 averaged 92.6% (range, 91.5–93.3%) for one dose, and 87.5% (range, 86.0–88.4%) for two doses by 25 weeks of age. 6 We also analysed laboratory-confirmed rotavirus infections reported by microbiology laboratories across England to Public Health England (PHE). Reporting by diagnostic laboratories is voluntary, but a recent survey in England indicated that laboratory testing and reporting practices are generally high and consistent year-round. 2 We extracted weekly counts (by date of specimen) of laboratory-confirmed rotavirus infections for children under 5 year olds between July 2000 and June 2014. During 2000/01 to 2012/13, the rotavirus season was consistently predictable, with well-defined peaks between January to March. In 2013/14, laboratory-confirmed rotavirus infections were 67% lower than the ten-season average for the same period in the seasons 2000/01 to 2012/13. 4 Prior to routine vaccination, the number of reported rotavirus infections increased from birth and peaked at 12 months of age. In 2013/14, the most substantial reduction was observed among 2–11 month olds, the age-group targeted for immunisation ( Fig. 1 ).

gr1

Figure 1 Weekly rotavirus laboratory reports in children younger than 5 years old by month of age, England 2000–2014. *Data are presented by month of age per epidemiological year, defined as running from July to June of the following year.

In order to identify any changes in laboratory testing practices, disaggregate data for the total number of rotavirus tests performed and test results were collected from eight sentinel NHS microbiology laboratories with the highest number of rotavirus testing in England. 6 Between January 2013 and June 2014, there were no changes in diagnostic guidelines at any of the participating sites. A total of 7681 samples were tested for rotavirus and 1214 (16%) tested positive in under 5 year olds. After the introduction of the rotavirus immunisation programme, a large volume of samples continued to be tested for rotavirus ( Fig. 2 A), with under 1 year olds consistently accounting for a quarter of all samples tested every month. The proportion of rotavirus test-positives, however, declined markedly during the first season after vaccine introduction, which was most marked in under 1 year-olds, but also noticeable in 1–4 year-olds who were not vaccine-eligible ( Fig. 2 B).

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Figure 2 Sample-testing data for children younger than five years of age from eight sentinel microbiology laboratories in England between January 2013 and August 2014. (A) Number of rotavirus test-positives and total rotavirus tests per month and (B) percentage of rotavirus positive tests by age-group per month.

Together, the reduction in laboratory-confirmed reports, lack of evidence of a change in rotavirus testing practice and the lower positivity rates specifically in the only age group with high vaccine coverage support a rapid and significant positive impact of the rotavirus immunisation programme on disease burden in England. Our results are similar to reports from the US, and other European countries with national rotavirus immunisation programmes. 1 In Belgium, for example, laboratory-confirmed rotavirus infections declined by 80% in under 1 year olds and 61% in under 5 year olds. 7 The main limitation of our findings is the assumption that the epidemiology would have remained similar if a vaccine had not been introduced, and that other factors would not change. England, like many other European countries, did experience a mild winter during 2013/14 with a higher mean winter temperature than the long-term average. 8 However, England has experienced milder winters in 2007, 1990, 1989 and 1998, 8 and rotavirus cases have never declined to such an extent in almost three decades of national surveillance. 2 Low birth rate as a possible explanation is also unlikely since birth rates in England have risen by 23% since 2001. 9 There was also no evidence of an unusual rotavirus strain causing relatively milder disease during 2013/14 (personal communication, David Allen, PHE Virus Reference Department, September 2014), with G1P[8] remaining the dominant strain along with a mixture of G2P[4], G3P[8], G4P[8], G8P[4], G9P[8] and G12P[8], as reported in previous years. 10

We conclude that immunisation against rotavirus has had a significant impact on burden of rotavirus disease in England within a year of vaccine introduction. Although naturally lower rotavirus activity was observed in the Netherlands during 2013/14, we could not identify any factor other than the infant immunisation programme to explain the decline in rotavirus disease in England. On-going national surveillance will continue to monitor the longer-term impact of rotavirus vaccination.

Conflict of interest

None.

Ethics approval

Public Health England has approval under Patient Information Advisory Group (PIAG) Section 60 of the Health and Social Care Act 2001 to process confidential information from patients for the purposes of monitoring the efficacy and safety of vaccination programmes.

Funding

Public Health England.

Acknowledgement

John Harris and Natalie Adams, Gastrointestinal Emerging and Zoonotic Infections Department, Public Health England for extracting the LabBase2 data. Joanne White, Immunisation, Hepatitis and Blood Safety Department, Public Health England for providing vaccine coverage data.

Appendix A. Supplementary data

The following is the Supplementary data related to this article:

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Supplementary Figure Weekly rotavirus laboratory reports for children under 5 years old, England 2000–2014. * Data are presented by epidemiological year, defined as running from July to June of the following year.

References

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  • 2 C.J. Atchison, B.A. Lopman, C.J. Harris, C.C. Tam, M. Iturriza Gomara, J.J. Gray. Clinical laboratory practices for the detection of rotavirus in England and Wales: can surveillance based on routine laboratory testing data be used to evaluate the impact of vaccination?. Euro Surveill. 2009;14(20) (pii):19217
  • 3 J.P. Harris, M. Jit, D. Cooper, W.J. Edmunds. Evaluating rotavirus vaccination in England and Wales. Part I. Estimating the burden of disease. Vaccine. 2007;25(20):3962-3970 [Epub 2007 Mar 15] Crossref
  • 4 Public Health England. Health Protection Report: weekly report. 2014;8(41)
  • 5 S. Hahne, M. Hooiveld, H. Vennema, A. van Ginkel, H. de Melker, J. Wallinga, et al. Exceptionally low rotavirus incidence in the Netherlands in 2013/14 in the absence of rotavirus vaccination. Euro Surveill. 2014;19(43) (pii):20945
  • 6 K. Russell, S. Ladhani, D. Brown, P. Kaye, C. Atchison. Proposed surveillance for the impact of the infant rotavirus immunisation programme in England and Wales. (, 2013) http://www.hpa.org.uk/webc/HPAwebFile/HPAweb_C/1317139475184 Available from:
  • 7 G. Hanquet, G. Ducoffre, A. Vergison, P. Neels, M. Sabbe, P. Van Damme, et al. Impact of rotavirus vaccination on laboratory confirmed cases in Belgium. Vaccine. 2011;29(29–30):4698-4703 10.1016/j.vaccine.2011.04.098 [Epub May 13] Crossref
  • 8 UK Met Office. UK mean temperature – winter. Available from: http://www.metoffice.gov.uk/climate/uk/summaries/actualmonthly . [accessed 05.12.14].
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Footnotes

Immunisation, Hepatitis and Blood Safety Department, Centre for Infectious Disease Surveillance and Control (CIDSC), Public Health England, 61 Colindale Avenue, London NW9 5EQ, UK

Virus Reference Department, Centre for Infectious Disease Surveillance and Control (CIDSC), Public Health England, 61 Colindale Avenue, London NW9 5EQ, UK

b Public Health Laboratory London, Barts Health NHS Trust, London E1 2ES

c Public Health Laboratory Newcastle, Freeman Hospital, Newcastle NE7 7DN

d Public Health Laboratory Birmingham, Heart of England NHS Foundation Trust, Birmingham B9 5SS

e Public Health Laboratory Leeds, Leeds Teaching Hospitals NHS Trust, Leeds LS1 3EX

f Public Health Laboratory Cambridge, Addenbrooke’s Hospital, Cambridge CB2 0QW

g Public Health Laboratory Manchester, Manchester Royal Infirmary, Manchester M13 9WZ

h Public Health Laboratory Southampton, Southampton General Hospital, Southampton SO16 6YD

i Public Health Laboratory Bristol, Bristol BS2 8EL

Corresponding author. Department of Primary Care and Public Health, Room 332, Reynolds Building, Imperial College London, Charing Cross Campus, London W6 8RF, UK. Tel.: +44 0207 5948703.

© 2015 The British Infection Association. Published by Elsevier Ltd. All rights reserved.

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PRT/ROT/0021/15a Data de preparação: 09/12/2015