PrimeCuts: This Week in the Journals

February 1, 2010

Shortcut 3Carolina Cabral MD

Faculty peer reviewed

As the world continues to witness the earthquake aftermath in Haiti, the stories and statistics become more unsettling. As the New York Times reported this week, after the devastating earthquake struck what was already one of the world’s most impoverished nations, Haiti saw the collapse or severe damage of 20,000 commercial buildings and 225,000 residences (1). The death toll has risen above 150,000 in the Port-au-Prince area alone, not to mention those who remain unaccounted for in both Port-au-Prince and its neighboring towns of Léogâne and Jacmel.

As rescue efforts have officially ceased, the focus has now shifted to providing aid to the more than 250,000 injured civilians and half a million people left homeless. Responding to the growing need for aid and medical assistance, a team of NYU doctors, led by Dr. Fritz Francois, of the Dept. of Medicine, Gastroenterology, helped to organize NYULMC-HEART (Haitian Effort and Relief Team). This team of healthcare providers included Prisca Bernard-Joseph, RN (Bellevue) Labor & Delivery/OR, David Feldman, MD, Pediatric Orthopaedics, Mary Ann Hopkins, MD, Surgery, Kenneth Mroczek, MD, Orthopaedic Surgery, Patricia Poitevien, MD, Pediatrics and Diana (Lucia) Voiculescu, MD, Anesthesiology. This team has just returned from a one-week mission to volunteer their time in a collaborative effort to provide surgical and medical services in Port-au Prince and most importantly to help out in any way they could. Their journey is detailed in a captivating blog that can be found at http://heart.med.nyu.edu/.

Recently highlighted in the BMJ as one of the worst natural disasters in recent years, the earthquake in Haiti wiped out much of the limited infrastructure of one of the world’s poorest countries (2). Margaret Chan, member of the World Health Organization and Director of its Department of Protection of the Human Environment, states: “We have every reason to be concerned about the health of survivors. Many of the problems we try to prevent after a disaster were already present in Haiti.” These problems include diseases associated with poor water and sanitation systems, low vaccination coverage, widespread malnutrition, outbreaks of infectious diseases, a high prevalence of HIV and tuberculosis, and “erratic delivery of medicines and care”. In times of such catastrophe, while emergency and critical care medicine are crucial, one must not forget the continued importance of preventative healthcare, as pointed out by Margret Chan, which are issues that affected Haiti long before the devastating earthquake.

In the spirit of preventative healthcare, we will discuss three articles published in the current issue of NEJM that look at the use of the rotavirus vaccine to prevent severe diarrhea and its other adverse health consequences. First, let’s discuss a study on the effect of the rotavirus vaccine on severe diarrhea in African infants (3). Rotavirus is the most common cause of severe gastroenteritis among children and is estimated by the World Health Organization (WHO) to account for approximately 527,000 deaths each year (4). Vaccines represent an invaluable resource in disease prevention. Previous studies have shown that two oral, live attenuated rotavirus vaccines, Rotarix (GlaxoSmithKline Biologicals) and RotaTeq (Merck), have excellent protective efficacy against severe rotavirus gastroenteritis (5,6,7). The current study is a randomized, placebo-controlled, multicenter trial in South Africa and Malawi conducted to evaluate the efficacy of a live, oral rotavirus vaccine in preventing severe rotavirus gastroenteritis. The vaccine was used in about 4500 infants who were randomly assigned to receive either two or three doses of the vaccine or placebo. Severe gastroenteritis caused by circulating rotavirus was detected in 4.9% of the placebo group as compared with 1.9% in the pooled vaccine group, a difference that was significant. The vaccine showed efficacy against severe rotavirus gastroenteritis both in infants who received two doses of vaccine and in those who received three doses. Rotavirus gastroenteritis prevention was greater in Malawi as compared to South Africa, owing to the higher incidence of severe rotavirus gastroenteritis in Malawi. On the basis of this study and other supporting data, SAGE recently recommended that rotavirus vaccination of infants be included in all national immunization programs, in conjunction with other proven interventions for diarrheal disease.

NEJM also published a retrospective study on the effect of rotavirus vaccine on death from childhood diarrhea in Mexico (8). Data was obtained on deaths from diarrhea, regardless of cause, from 2003 through 2009 in Mexican children under the age of five. This time span encompasses both the pre and post-rotavirus vaccine eras. Vaccine coverage was estimated from administrative data. In 2008, there were 1118 diarrhea-related deaths among children younger than five years of age, a reduction of 675 from the annual median of 1793 deaths during the 2003-2006 period before the rotavirus vaccine. Diarrhea-related mortality fell from an annual median of 18.1 deaths per 100,000 children at baseline to 11.8 per 100,000 children in 2008. The reduction in the number of diarrhea-related deaths persisted through two full rotavirus seasons (2008 and 2009).

On the downside however, recent data showed vaccine-acquired Rotavirus in infants with severe-combined immunodeficiency (8). The vaccine is currently recommended for routine childhood immunization, and pre-licensure and post-licensure data indicate that the vaccine is efficacious and has a low risk of associated adverse events and that administering live rotavirus vaccine is not absolutely contraindicated in persons with compromised immune systems. While HIV positive children were included in the above studies, there have been 3 case reports of rotavirus disease detected after the administration of the vaccine in infants with severe- combined immunodeficiency.

Undoubtedly there is much work to be done in terms of financial and medical assistance to Haiti as well as in the sector of preventative health both domestically and abroad. However, amid the turmoil and tragedy, there are signs of hope. This week in the New York Times, David Harland, a senior United Nations official stated: “While reeling from the quake, Haitians had already managed to re-establish a cell phone network, get remittances flowing from relatives overseas and bring in produce from the countryside, all helping the country start ticking on its own.” (9).

Dr. Cabral is a 2nd year resident in internal medicine at NYU Medical Center.

Peer reviewed by Danise Schiliro-Chuang MD, Contributing Editor, Clinical Correlations.

References

1. The Associated Press. A Glance at Haiti Developments 16 Days After Quake. The New York Times. 2010 Jan 28.

2. Moszynski P. Damage to Haiti’s infrastructure is “almost unbelievable”. British Medical Journal. 2010 Jan 20; 340:c378.

3. Madhi S, et al. Effect of Human Rotavirus Vaccine on Severe Diarrhea in African Infants. NEJM. 2010 Jan 28; 362:289-298.

4. World Health Organization. Rotavirus vaccines. Wkly Epi Rec 2007; 82:285296.

5. Vesikari T, Matson DO, Dennehy P, et al. Safety and efficacy of a pentavalent human-bovine (WC3) reassortant rotavirus vaccine. NEJM. 2006 Jan 5; 354:23-33.

6. Ruiz-Palacios GM, Pérez-Schael I, Velázquez FR, et al. Safety and efficacy of an attenuated vaccine against severe rotavirus gastroenteritis. NEJM. 2006 Jan 5; 354:11-22.

7. Araujo EC, Clemens SA, Oliveira CS, et al. Safety, immunogenicity, and protective efficacy of two doses of RIX4414 live attenuated human rotavirus vaccine in healthy infants. J Pediatr (Rio J) 2007; 83:217-224.

8. Richardson V, et al. Effect of Rotavirus Vaccination on Death from Childhood Diarrhea in Mexico. NEJM. 2010 Jan 28; 362:299-305.

9. Patel N, et al. Vaccine-Acquired Rotavirus in Infants with Severe Combined Immunodeficiency. NEJM. 2010 Jan 28; 362:314-319.

10. MacFarquhar N. Haiti Is Again a Canvas for Approaches to Aid. The New York Times. 2010 Jan 30.

 

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