Use of disease surveillance to inform new vaccine introduction

1. Use of disease surveillance to inform new vaccine introduction Insert name of Presenter Annual Regional Conference on Immunization (ARCI). Dar-es-Salaam, Tanzania 10 to 12 December 2012 Annual Regional Conference on Immunization (ARCI); Dar-es-salaam, Tanzania, 10-12 December 2012

2. Introduction • Pneumonia and diarrhoea are the common causes of under 5s morbidity and mortality globally, causing 29% of deaths ≈ 2 mill. lives lost each year, • 90% occur in sub-Saharan Africa and South Asia. • In Tanzania they cause nearly one-third of all U5 deaths. • Rotavirus and Pneumococcal infants account for a significant proportions of these data. Source: World Health Report 2008 Annual Regional Conference on Immunization (ARCI); Dar-es-salaam, Tanzania, 10-12 December 2012

3. Introduction: Prevalence • The reported prevalence of Pneumococcal infections in Tanzania is between- (data to be added) • Local Studies reported prevalence rotavirus infection of 8.4 -43% (Brookfield e al 1976, Mhalu et a 1992, Sam et al 1992,Temu M et al 2002, , Gascon et al – 2000, Moyo et al 2007, Temu A et al 2009) • PBM+IBD/Rotavirus surveillance was initiated in Tanzania in July 2001. Annual Regional Conference on Immunization (ARCI); Dar-es-salaam, Tanzania, 10-12 December 2012

4. New Vaccine Surveillance • Rotavirus/IBD/PBM surveillance was initiated Tanzania for the following purposes; • To estimate the incidence of hospitalizations associated with rotavirus/IBD among under-fives. • To determine the age and seasonal distribution of hospitalizations associated with rotavirus/IBD among under-fives. • To estimate the proportion of diarrhoea/ IBD hospitalizations attributable to rotavirus/HiB, pneumococcal among children under-fives. • To identify and characterize the prevalent strains in preparation for the introduction of vaccines. Annual Regional Conference on Immunization (ARCI); Dar-es-salaam, Tanzania, 10-12 December 2012

5. New Vaccine Surveillance sites Invasive bacterial Disease (IBD) inclPaediatric Bacterial Meningitis (PBM) surveillance. • Initiated at Muhimbili National Hospital in Oct 2001. • Muheza DDH in 2005. • Hydom hospital in 2007 • Bugandomedical centre in 2010. Rotavirus Gastroenteritis surveillance (RGS) • Initiated in Tanga (Bombo Hospital) – 2007. • Zanzibar (Mnazi Mmoja) and Mwanza (Bugando Medical Centre)- 2010. Annual Regional Conference on Immunization (ARCI); Dar-es-salaam, Tanzania, 10-12 December 2012

6. Methodology: Rotavirus Using WHO SOPs for rotavirus surveillance • Children under 5 years of age who were hospitalized with acute diarrhea were enrolled, and their stool specimens were collected. • Enzyme immunoassay- DAKO kits were used to detect rotavirus. • Rotavirus positive samples were sent to Regional reference laboratory (RRL) in Medunsa for quality control and genotyping. • Rotavirus strains were characterized for G and P types with use of a reverse-transcriptase polymerase chain reaction (RT-PCR). Annual Regional Conference on Immunization (ARCI); Dar-es-salaam, Tanzania, 10-12 December 2012

7. Results: Rotavirus • From Nov 2007-June 2012; 2022 children were enrolled into the surveillance. • 1998 (98%) stool samples were collected and 796 (40%) were positive for rotavirus. • 308 (38.6%) specimens were sent to Regional Reference laboratory (RRL) for genotyping. • Infection was all year around with seasonal peaks and seasonal peaks, varied from year to year Jan-Feb in the first 2 years and Apr-June in the last two years. • 88% of all rotavirus infections occurred among children below one year of age. • Rotavirus infection was associated with a prolonged hospital stay and dehydration. Annual Regional Conference on Immunization (ARCI); Dar-es-salaam, Tanzania, 10-12 December 2012

8. Incidence of Rotavirus cases quarterly Annual Regional Conference on Immunization (ARCI); Dar-es-salaam, Tanzania, 10-12 December 2012

9. Rotavirus Positive cases by age group From Nov 2007 to June 2012 Annual Regional Conference on Immunization (ARCI); Dar-es-salaam, Tanzania, 10-12 December 2012

10. Rotavirus circulating genotypes 2008 - 2011 Annual Regional Conference on Immunization (ARCI); Dar-es-salaam, Tanzania, 10-12 December 2012

11. Methodology: Hib-PBM Surveillance • Active sentinel surveillance of PBM was carried out in accordance with WHO/AFRO guideline with enhancement to include invasive disease by netSpear- at Muheza site. • LP was performed on all Suspected Bacteria Meningitis after obtaining consent A suspected case of pediatric bacterial meningitis • child 0-59 months of age with • sudden onset of fever (>38◦C axillary or >38.5◦C rectal) and • at least one of the following: neck stiffness, bulging fontanelle, altered consciousness, irritability, petechial of purpural rash, toxic appearance or other meningeal signs. Annual Regional Conference on Immunization (ARCI); Dar-es-salaam, Tanzania, 10-12 December 2012

12. Methodology: Hib-PBM Surveillance • Meningitis was confirmed by isolation of H. influenzae, S. pneumoniae or N. meningitidisfrom CSF (or positive latex test, if available) • For IBD - Blood was collected from cases of septicaemia and sent to laboratory for inoculation in culture media and incubation • All isolates were stored at -20⁰C, later were sent to RRL- Kilifi Kenya for serotyping. • All data are entered in Epi-Info and analyzed according to standard indicators per WHO guidelines • Quality control was done regularly from regional reference laboratory Annual Regional Conference on Immunization (ARCI); Dar-es-salaam, Tanzania, 10-12 December 2012

13. Results: PBM Surveillance • Between Oct 2001 and Dec 2008 BEFORE the introduction of Hib vaccine, a total of 2600 cases of suspected meningitis cases were reported from 3 sentinel sites. • 2540 (93%) had a lumbar puncture performed and results logged in the database. • 467 (17 %) of specimen were purulent, 215(46%) CSF specimen were purulent but culture results were negative. • 252 (56%) were culture positive, 53 (21%)for Haemophilusinfluenzaeand 68(26%) For S. Pneumoniae, and 138 (53%) for other organisms. • A total of 11 serotypes were isolated, 90 % of these isolates are present in PCV13 • AFTER the introduction of Hib vaccine, a total of 142 cases of suspected meningitis cases were reported from one sentinel site (Muheza DDH) and lumbar puncture performed. Annual Regional Conference on Immunization (ARCI); Dar-es-salaam, Tanzania, 10-12 December 2012

14. Results: PBM surveillance Annual Regional Conference on Immunization (ARCI); Dar-es-salaam, Tanzania, 10-12 December 2012

15. Confirmed meningitis cases Annual Regional Conference on Immunization (ARCI); Dar-es-salaam, Tanzania, 10-12 December 2012

16. Streptococcus pneumoniaesero types • Serotype 13 and Annual Regional Conference on Immunization (ARCI); Dar-es-salaam, Tanzania, 10-12 December 2012

17. Data analysis, sharing and use of surveillance data • Hospital administration? • Clinicians • MOHSW Annual Regional Conference on Immunization (ARCI); Dar-es-salaam, Tanzania, 10-12 December 2012

18. New Vaccine introduction • Evidence provided has led to Tanzania deciding to introduce 2 new vaccines • Rotavirus and pneumoccocalvaccine into the routine immunization programmein Jan 2013. • Vaccines to be introduced are • Rotarix - human monovalent vaccine G1[P8] with a potential for cross protection. • Pneumococcal conjugate vaccine 13. Annual Regional Conference on Immunization (ARCI); Dar-es-salaam, Tanzania, 10-12 December 2012

19. Preparation of introduction • Tanzania’s First Lady in the 1st National Advocacy meeting Activities done and on going, • expansion of cold chain at the national and regional region. • guidelines for NVI has been prepared and printed ready for distribution. • Cascaded trainings from National to health facility level. • Advocacy and sensitization to immunization stakeholdersincluding the media. • Community mobilization Annual Regional Conference on Immunization (ARCI); Dar-es-salaam, Tanzania, 10-12 December 2012

20. Conclusion • Rotavirus infection is responsible for 40% of severe gastroenteritis in surveillance sites in Tanzania • G1P8, G8P4, G2P4 are responsible for 68% of Rotavirus infections • S. Pneumoniae is responsible for about 26% of paediatric meningitis in surveillance sites Tanzania. • while ……were the majority in Meningitic patients • It is important to continue with surveillance after vaccine introduction and also to monitor adverse events, efficacy of vaccine and possible genotype variability. • Tanzania is now preparing to introduce Rotavirus and Pneumococcal vaccines in Jan 2013 Annual Regional Conference on Immunization (ARCI); Dar-es-salaam, Tanzania, 10-12 December 2012

21. Way forward: New Vaccine Surveillance • 2 more sites to conduct start new vaccine surveillance; Dar and Mbeya • To monitor efficacy of vaccine, possible genotype variability and AEFI. Annual Regional Conference on Immunization (ARCI); Dar-es-salaam, Tanzania, 10-12 December 2012

22. acknowledgements . • New vaccines Surveillance Sentinel sites Teams- Mwanza, Hydom, Muheza, Tanga and Zanzibar • MOHSW/IVD - Tanzania Mainland and Zanzibar • WHO Country Office • WHO AFRO • RRL-Medunsa- University of Limpopo • Other partners, donors and stake holders in NVI Annual Regional Conference on Immunization (ARCI); Dar-es-salaam, Tanzania, 10-12 December 2012

23. Thank you!!!! Ahsantenisana!!! Annual Regional Conference on Immunization (ARCI); Dar-es-salaam, Tanzania, 10-12 December 2012

24. Introduction: Pneumonia • Invasive pneumococcal disease is caused by the bacterium Streptococcus pneumoniae • Clinical manifestations of S. pneumoniae infections in young children are serious and include pneumonia, meningitis, sepsis, bacteremia, otitis media, abscesses, and bone and joint infections. • Worldwide, it is the most common cause of bacterial pneumonia mortality and the most severe cause of bacterial meningitis in children under five years of age. Annual Regional Conference on Immunization (ARCI); Dar-es-salaam, Tanzania, 10-12 December 2012