My First Academic Essay: Implementing Rotavirus Vaccination in Indonesia

This is my first 5 pages academic essay in English as an assignment for my vaccinology course. I publish this essay because during my writing process, I had difficulty to look for some data, especially when I sought data from my country. Besides, this topic is not too academic, quite easy to understand and it might useful for those who are interested. I just remember a nice quote from my Mexican friend,”live is sharing, sharing is life”, so hopefully my essay would somehow be useful.

I also put the essay requirements from my lecture, just in case somebody want to know more in detail.

Phf…I am really glad that I can finish my essay even though in the last minutes, next time should be better (yes, 10 pages of cancer essay is waiting…huhuhu..but I like it though, I learn a lot!)

Introduction
Rotavirus is the most common cause of severe, dehydrating diarrhea of infants in both industrial and developing countries (WHO, 2011). Each year rotavirus causes about 111 million cases of infantile gastroenteritis requiring home care only, 25 million clinic visits, 2 million hospitalizations, and more than 500.000 deaths in children less than 5 years (RVP, 2008). Nearly every child affected by rotavirus infection before the fifth birthday ( Parashar et all, 2003). The highest mortality, 85% of rotavirus deaths, occur in the poorest countries (RVP, 2008).
Deaths worldwide due to rotavirus, more than 55 % are predicted to occur in Asia (Bresee J.S. et all, 2005). According to IRSN (Indonesian Rotavirus Surveillance Network) in 2006, 60 % of diarrheal disease in Indonesia for children under 5 years is due to rotavirus, and particularly occur in children age 6-24 months (Soenarto et all. 2009).

Although efforts to enhance sanitation and hygiene have decreased the overall incidence of diarrheal disease, the occurrence of rotavirus diarrhea have remained the same. Government in Indonesia has suggested the latest developments guideline for diarrhea treatment to be used, however, practices in the field persists (Soenarto Y, 2008).
Moreover, despite the efficacy of Oral Rehydration Solutions (ORS) for management of all diarrhea diseases including rotavirus, many children still die due to rotavirus. The children are die because of limited access or insufficient use of ORS (Santhosam et all. 2007).

Development of rotavirus vaccine has been recommended as the best strategy for reducing morbidity and mortality associated with rotavirus infection (Santhosam et all. 2007). Factors of hygiene, sanitation, environment and social economy do not influence the high morbidity of rotavirus diarrhea in both developing and developed countries. In the absence of causative therapy for this virus, the presence of vaccine is a new hope for diarrhea treatment caused by rotavirus (Soenarto Y, 2008).

However, implementing rotavirus vaccine or any other new vaccines to national immunization program need multifactor consideration, such as social values, perceptions, political concerns, and not just technical considerations (WHO, 2000).

The objectives of this essay are to analyze why rotavirus vaccine is needed in Indonesia and to determine the challenges for implementing rotavirus vaccination in Indonesia.

Burden of Disease
Indonesia as one member of the ARSN (Asian Rotavirus Surveillance Network) also founded IRSN (Indonesian Rotavirus Surveillance Network) with six members of teaching hospitals. Since 2001, longitudinal survey of rotavirus infection has been conducted in six hospitals in Indonesia through IRSN, with generic protocol from WHO. According to a survey of rotavirus surveillance in 2001-2004 in Central Java and Jogjakarta, around 53 % of children under 3 years with diarrhea, infected by rotavirus. G1, G2, G4 and combination G1P and G4P were the most detected strain rotavirus. In addition, rotavirus infection occurs mostly in dry season (Wilopo et all. 2009) . Furthermore, prospective surveillance in 2006 showed that rotavirus were responsible for 60 % severe acute diarrhea in children under 5 years, mainly children ages 6-24 months old. The most detected genotype rotavirus in this survey were P type strain and G9P, which are untypical. The survey also found that rotavirus infection occurs throughout the year without depending on seasonal variation (Soenarto et all. 2009).

Management of Diarrhea in Indonesia
Rehydration, re feeding, using medicine, and communication between patient and health workers are principals of diarrhea management. Based on Indonesian scientist researches, household liquids such as soup, water, starch, coconut water, salt sugar solution, and solution of various sugars have a similar effect with the ORS (Pardede et all. 1982). These studies change the guideline of diarrhea management, and in 1988 feeding became a treatment of diarrhea along with ORS and fluid household. Tempeh is a typical Indonesian food that meets proper nutrition for feeding treatment in diarrhea patients. Research in Indonesia showed that giving food or formula based on tempeh can shorten the duration of acute diarrhea, and accelerate recovery (Soenarto et all. 1997).

Anti diarrhea, antibiotics and Zinc
Antidiarrheal agents such as adsorbent (e.g., kaolin-pectin), antimotility agents (e.g., loperamide), antisecretory drugs, or toxin binders (e.g., cholestyramine), often use both in developed and developing countries. However, studies do not show that antidiarrheal agents effective to reduce diarrhea volume or duration (CDC, 2001).
Regarding to diarrhea treatment with antibiotics, irrational use of antibiotics have been widely reported since many decades ago, including in Indonesia (Soenarto Y, 2008). Since bacterial resistances to co-trimoxazole have been increasing, WHO has recommended ciprofloxacin to replace co-trimoxazole. However, ciprofloxaxin has chondrotoxic effects to the bone growth, which is means, other safer therapies should be sought (Bhutta et all. 2000).

Meta-analysis study showed that the duration and severity of acute diarrhea and persistent diarrhea can be reduced by zinc therapy (Lukacik et all. 2007). The Indonesian government is trying to include zinc to the national diarrhea guideline and is expected to be implemented in upcoming years (Soenarto Y, 2008).

The important of implementing rotavirus vaccine
A study in Indonesia found that doctors who work both for public or private prescribe drugs, especially antibiotics, more often than ORS. Nutritional advice is also given less frequent than antibiotics (DD online, 1991). Moreover, research from 5 provinces in Indonesia in 2003 found that 85% children with diarrhea have been given antibiotics (Dwiprahasto, 2003). According to a survey, more than half of children with diarrhea, in fact are not given ORS, and only few children are given fluid more than usual (BPS, 2007). Indonesian government and health workers have proclaimed the latest developments guideline of management diarrhea. Nevertheless, practices in the field remains far from expectations (Soenarto Y, 2008).

Furthermore, rotavirus has a unique global scope. Approximately every child in the world will obtain at least one rotavirus infection before age of five without considering geography, socio-economic status or gender. Rotavirus also has special management rules compare to other diarrheal diseases. Preventing rotavirus infection by sanitation, and access to clean water are not adequate. Excessive and persistent vomiting usually follows severe cases, and ORS is very difficult to be given. Providing a vaccine is the most effective method to prevent rotavirus infection (Simpson et all. 2007)
Current findings in January 2011 concluded that rotavirus vaccines have significant impact on children’s health in developed and developing countries that have started the vaccines. The vaccines have dramatically reduced the number of children hospitalized due to rotavirus in countries that implement rotavirus vaccines in their national immunization programme (PATH, 2011).
Since several years ago, the development and distribution of rotavirus vaccines in developing countries has been prioritized by WHO (2003). To promote the availability of safe and efficacious rotavirus vaccines for children in developing countries, the GAVI Alliance are moving together with manufacturers, governments, and global health organizations (GAVI, 2003). In 2009,WHO recommend all countries to insert rotavirus vaccines in their national immunization programs (PATH, 2011).

Rotavirus Vaccine
Two current rotavirus vaccines are available and used routinely in many countries. Studies showed that the vaccines are safe and there is no increasing frequency of intussusceptions. Approximately, two million deaths could be prevented in the next decade, with the extensive use of this vaccines (Shantosam M, 2010).

However, the vaccines price are too expensive for children in developing countries, even with subsidization. In order to be able to provide protection, the vaccines also should be given in a timely way, in the early months of age. Therefore, RV3 vaccine from Australia has been developed, and the phase II trials will start this year in New Zealand and Indonesia (Bines J, 2010).

RV3 is an unique attenuated vaccine (Medscape, 2010). The vaccine is called a Human Neonatal Rotavirus strain, since it has been based on a rotavirus infection in young infants,. This neonatal strain would provide specific advantages and a good safety profile for babies at birth (Bines J, 2010). To reduce production costs, patents of this vaccine has been given to Indonesia (Soenarto Y, 2008). By initially targeting the children of Indonesia and provide vaccine made in Indonesia, the implementation of this vaccine in a large population could be established (Bines J, 2010).

Challenges
However, although using rotavirus vaccine to decrease the risk of death from diarrhea is promising, there are many obstacles to implement this vaccine in developing countries (Shantosam et all. 2007). According to the (WHO, 2005) there are two group of issues to consider for implementing a new vaccines. Policy issues as the first group of issues are: public health priority, disease burden, efficacy, quality, safety, other interventions (including other vaccines), economic and financial issues. The second group of issues, referred to as programmatic issues: vaccine presentation, supply availability, programmatic strength addresses the feasibility of the vaccine introduction from a technical perspective.

Policy Issues Challenge
Regarding public health priority in developing countries including Indonesia, knowledge and awareness of the public health community about rotavirus is still lacking. Whereas, a key factor to obtain vaccine introduction is the public health priority of the disease (Simpson et all. 2007). Knowledge and awareness that rotavirus causes most of severe diarrhea cases in children is also low. As a result, at individual level, a child who obtained rotavirus vaccine and then experiences diarrhea will interpret falsely as a ‘vaccine failure’ by parents or physicians although the diarrhea is due to another cause. Developing communication strategies that put the role of rotavirus vaccine into a fit context of whole diarrheal disease management is needed (GAVI, 2006).

Another challenge in implementing rotavirus vaccine in Indonesia is about safety. Although studies have shown that the new vaccines are safe, the experience of intussusceptions of the previous vaccine still has impact of mistrust (Soenarto Y, 2008).

In term of economic and financial issues, implementation of rotavirus vaccine should be cost-effective. If the price of the vaccine is not affordable, it would be difficult to implement rotavirus vaccine in the national program. An economic evaluation to assess the potential for introducing rotavirus vaccine into Indonesia’s National Immunization Program showed that if the price of rotavirus vaccines cannot be reduced below $ 12.7 per child, the national immunization program cannot be applied (Wilopo et all. 2009). Determining the financial resources are important not only for the co-payment during the investment periods, but also the entire cost of the vaccine, even at the market mature price (GAVI, 2006).

Programmatic Issues Challenge
According to GAVI (2006), the existence of systemic safety surveillance with strict standard of quality is very important. Safety surveillance is imperative to determine adverse events, including intussusceptions, that might occurs due to introducing the vaccine in routine vaccination programs to the colossal of children with different vaccine schedules.

Regarding logistics, the storage and shipment of the vaccines to prevent cold-chain breaks have more complicated problem compare to those of typical childhood vaccines. This situation will make the logistics of vaccination programs in developing countries more challenging (Shantosam, 2010).
Other challenges include vaccine supply. All vaccine markets should assure sufficient supply to meet additional demand particularly in the beginning of market development (GAVI, 2006).

Conclusion
Rotavirus related diarrheal disease is a leading cause of mortality and morbidity in children under five years worldwide, particularly in developing countries. In Indonesia, 60 % of diarrheal disease in children under 5 years is due to rotavirus. The latest development of diarrhea disease management has been recommended in Indonesia, nevertheless, the condition remains the same. Rotavirus infection is a special disease that not only need traditional preventing methods such as hand washing and sanitation, but also require a powerful weapon. Rotavirus vaccine is considered as the most effective tool to prevent the disease. Current studies showed that rotavirus vaccine has dramatic impact to reduce severe and fatal diarrhea.

The high burden of rotavirus infection in Indonesia proves that rotavirus vaccine should be introduced immediately. RV3 Human Neonatal Rotavirus strain has been developed, and the initial phase II trials that targeting Indonesian children is going to start this year. Providing vaccine made in Indonesia and giving patents to Indonesia will help to reduce production costs. However, Indonesia faces many challenges to implement the vaccine into the national immunization program, both policy and pragmatic issues. For implementing the vaccine in this country, the decision makers should be aware with those challenges, and each factors must be carefully thought, planned and monitored.

References
Bines J, 2010, ‘Newborns’ Rotavirus Vaccine Begins Trials’, viewed at 26 February 2011,
http://www.abc.net.au/ra/innovations/stories/s2991009.htm

Bresee, JS, Hummelman, E, Nelson, EA, & Glass, RI 2005,’Rotavirus in Asia: the value of surveillance for informing decisions about the introduction of new vaccines,’ Journal Infectious Diseases, 192, Sep, Suppl 1:S1-5.

Bhutta, ZA, Bird, SM, Black, RE, Brown, KH, Gardner, JM, Hidayat, A, Khatun, F, Martorell, R, Ninh, NX, Penny, ME, Rosado, JL, Roy, SK, Ruel, M, Sazawal, S, & Shankar A 2000,’Therapeutic effects of oral zinc in acute and persistent diarrhea in children in developing countries: pooled analysis of randomized controlled trials 1–3,’ Am J Clin Nutr, vol.72, pp.1516–22.

Indonesia Demographic and Health Survey (BPS) 2007, Gross Domestic Product and Per Capita Income, viewed 23 February 2011, http://www.bps.go.id/sector/nra/gdp/table7.shtml.

Centers for Disease Control and Prevention (CDC) 2001, ‘The Management of Acute Diarrhea in Children: Oral Rehydration, Maintenance, and Nutritional Therapy, viewed 21 February 2011, http://www.cdc.gov/mmwr/preview/mmwrhtml/00018677.htm

Dialogue on Diarrhea Online (DD online) 1991, viewed 22 February 2011, http://rehydrate.org/dd/dd44.htm

Dwiprahasto, I 2003, The use of anti diarrheal viewed from the aspect of rational therapy, paper presented at the Second National Congress of Gastroenterology Children Coordinating Board of Indonesia, Jakarta.

Global Alliance for Vaccines and Immunization (GAVI) 2003, ‘GAVI and The Vaccine Fund announce $60 million boost to accelerate development of lifesaving vaccines,’ viewed at 26 February 2011, http://www.gavialliance.org/media_centre/press_releases/2003_02_11_en_press_110203.php

Global Alliance for Vaccines and Immunization (GAVI) 2006,’ Accelerating the Introduction of Rotavirus Vaccines into GAVI-Eligible Countries,’ viewed at 25 February 2011, www.gavialliance.org/resources/Rotavirus_Investment_Case_Oct06.pdf

Lukacik, M, Thomas, RL, & Aranda, JV 2007,’ A Meta-analysis of the Effect of Oral Zinc in the Treatment of Acute and Persistent Diarrhea, Pediatrics,vol.121, no.2, pp.326-336.

Medscape, 2010,’Update on Rotavirus Vaccines: Human Rotavirus Strain Vaccines,’ viewed at 25 February 2011, http://www.medscape.com/viewarticle/517392_7

Parashar, UD, Hummelmann, EG, Bresee, JS, Miller, MA, & Glass, RI 2003,’ Global illness and deaths caused by rotavirus disease in children. ‘, Emerging Infectious Diseases, May, Vol. 9, No. 5.

Pardede, N, Djamil, H, & Ismail, 1982, Benefit of starch water as a substitute of ORS for treating severe dehydration in children with acute diarrhea in child health department Medical Faculty Sriwijaya University/General District Hospital Palembang, presented at the Annual Scientific Meeting of Child Gastroenterology VIII Coordinating Board of Indonesia, Semarang.

Program for Appropriate Technology in Health (PATH) 2011, ‘Rotavirus vaccines are improving the health and well-being of children by substantially reducing severe and fatal diarrhea,’ viewed at 25 February 2011, http://www.path.org/news/pr110120-pidj.php

Rotavirus Vaccine Program 2008, ‘Rotavirus Facts,’ viewed 14 February 2011, http://www.rotavirusvaccine.org/rotavirus-facts.htm

Simpson, E, Wittet, S, Bonilla, J, Gamazina, K, Cooley, L, & Winkler, JL 2007, ‘Use of formative research in developing a knowledge translation approach to rotavirus vaccine introduction in developing countries,’ vol.7, no. 281, viewed at 24 February 2011, http://www.biomedcentral.com/1471-2458/7/281

Santosham, M, Nelson, EA, & Bresee, JS, 2007,’Implementing rotavirus vaccination in Asia,’ Vaccine, vol.25, no.44, pp. 7711-6.

Santosham M, 2010, ‘Rotavirus Vaccine — A Powerful Tool to Combat Deaths from Diarrhea,’ N Engl J Med, vol.362, pp.358-360, viewed at 27 February 2011, http://www.nejm.org/doi/full/10.1056/NEJMe0912141

Soenarto, Y, Sudigbia, IH, Karmini, M, & Karyadi D, October 1997, Antidiarrheal characteristic of tempe produced traditionally and industrially in children aged 6-24 months with acute diarrhea, paper presented at the national symposium on Utilization of Tempe for improving nutritional status and health, Jakarta.

Soenarto Y, June 2008, Translational research and evidence-based policy: diarrhea in children as a case study, paper presented at the inaugural speech as professor of pediatrics Gajah Mada University, Jogjakarta.

Soenarto, Y, Aman, AT, Bakri, A, Waluya, H, Firmansyah, A, Kadim, M, Martiza, I, Prasetyo, D, Mulyani, NS, Widowati, T, Soetjiningsih, Karyana, IP, Sukardi, W, Bresee, J, & Widdowson, MA 2009,’Burden of severe rotavirus diarrhea in Indonesia,’200, Nov, Suppl 1:S188-94.

Wilopo, SA, Kilgore, P, Kosen, S, Soenarto, Y, Aminah, S, Cahyono, A, Ulfa, M, & Tholib, A 2009, ‘Economic evaluation of a routine rotavirus vaccination programme in Indonesia,’Vaccine, Nov, 27, Suppl 5:F67-74.

Wilopo, SA, Soenarto, Y, Bresee, JS, Tholib, A, Aminah, S, Cahyono, A, Gentsch, JR, Kilgore, P, & Glass RI, 2009, ‘Rotavirus surveillance to determine disease burden and epidemiology in Java, Indonesia, August 2001 through April 2004,’Vaccine, 27, Nov, Suppl 5:F61-6.

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Guidelines for the Written Assignment
The objective of the assignment is to t
est the student’s ability to present his or her thoughts in an organized way.

A written academic essay (Times New Roman font size 12, five pages excluding references and tables, Harvard Style referencingi) has to be handed in by 28 February 2011 to Institute of Tropical Medicine and International Health, Charité – Universitätsmedizin Berlin, in order to obtain 2.0 European ECTS credit points towards the tropEd Master of Science degree in International Health.

The essay should contain suggestions for intervention and/or research. All substantial facts need to be corroborated by references to the literature. Such references as well as quotations and other supporting material used in the assignment need to appear in the reference list at the end of the text. This allows evaluating to which extent the arguments in the essay are supported by evidence, and of which quality that evidence is.
Title
The title should be brief and concise. The main topic of the essay should be clearly indicated.
Introduction
The introduction should include the background or context of your topic, a statement of the problem as well as the objectives of your essay.
Main Part
It includes a presentation and discussion of current arguments and facts on your topic with reference to published work. Strengths and weakness, gaps, pro- and contra- arguments are analyzed and can be illustrated with examples. Always relate, verify and discuss your thoughts using what other people have brought up and published before.
Conclusion
The main points of your discussion should be summarized, and recommendations for research, policy
or practice should be formulated.

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