Preparing for rotavirus vaccine introduction – A retrospective assessment of the epidemiology of intussusception in children below 2 years of age in Nepal
Introduction
Diarrhea is the second most common cause of death in Nepali children [1], and rotavirus is the most common cause of severe diarrhea in these children, accounting for 25–33% of childhood diarrhea hospitalizations [2], [3]. Because of this substantial burden of disease, the Government of Nepal has included rotavirus vaccine on its priority list for new vaccines and plans to include rotavirus vaccine in the national immunization programme in the near future.
In 1999, a first generation oral rotavirus vaccine, Rotashield (Wyeth-Lederle), was withdrawn from the US market because of an increased risk of intussusception, estimated at one excess case occurring among every 10,000 vaccinated children, primarily in the first week after the first vaccine dose [4], [5]. The two currently licensed oral rotavirus vaccines, Rotarix (GlaxoSmithKline Biologicals, Rixensart, Belgium) and RotaTeq (RotaTeq, Merck and Co., Whitehouse Station, New Jersey), were assessed for intussusception in large pre-licensure clinical trials [6], [7]. While no increased intussusception risk was observed in these trials, post-marketing studies in several upper middle to high income countries have detected a small increased risk of intussusception associated with both vaccines, with an estimated 1–5 excess cases per 100,000 vaccinated children [8], [9], [10], [11], [12], [13]. Therefore, the World Health Organization recommends monitoring for intussusception in countries implementing rotavirus vaccines [14].
Intussusception is a rare condition in which the invagination of one segment of the bowel into another distal segment can result in obstruction, vascular compromise, necrosis of the intestine, perforation and even death if untreated. It is the most common cause of acute bowel obstruction in children below two years of age, with an estimated mean global incidence of 74 cases (range: 9–328) per 100,000 children aged < 1 year [15]. However, the incidence of intussusception varies substantially by geographic region and limited data on intussusception are available from low income countries of Asia and Africa. Genetic predisposition, circulating pathogens, differences in feeding practices and environments, and differences in access to health care and diagnostic practices could also contribute to the global differences in intussusception rates [15].
Data on the epidemiology of intussusception-associated hospitalizations are currently lacking in Nepal. Hence, we examined the immediate clinical outcomes and described the epidemiology of intussusception-associated hospitalizations among children in Nepal in preparation for rotavirus vaccine introduction.
Section snippets
Methods
We conducted a retrospective review of intussusception hospitalizations for a three year period from 1 July 2011 through 30 June 2014 at Kanti Children’s Hospital (KCH), Maharajgunj and Ishan Children and Women’s Hospital Pvt Ltd (ICWH), Basundhara, two major pediatric hospitals in Kathmandu, Nepal. These two sites were selected as they receive the majority of pediatric surgical case referrals and manage the majority of pediatric intussusception cases in Nepal. KCH is a public facility
Results
Overall, we identified 106 possible cases of intussusception in children age < 24 months admitted to KCH and ICWH during the 3-year study period. Of the 106 cases, three (3%) had their specific age missing and 18 (17%) did not meet the Brighton Collaboration level 1 diagnostic criteria, so these cases were excluded. A total of 85 cases (74 [87%] from KCH and 11 [13%] from ICWH) were included in the analysis (Fig. 1); over half (68%) were children from the Central Development Region of Nepal
Discussion
This study provides baseline epidemiological information on naturally occurring intussusception among children aged < 24 months in Nepal. Important to note is the lack of cases that occurred during the first 3 months of life and the low mortality rate, despite the fact that all cases underwent surgical intervention. Our findings are consistent with other reports from the United Kingdom, Republic of Ireland, Australia, and Malaysia that have described the peak age of intussusception incidence
Conflicts of interest
The authors declare that they have no conflicts of interest relevant to this article to disclose.
Disclaimer
The finding and conclusions of this report are those of the authors and do not necessarily represent the official position of the US Centers for Disease Control and Prevention.
Acknowledgements
Financial support for this evaluation was provided by Gavi, the Vaccine Alliance through the CDC Foundation. We would like to thank all the doctors, nurses and supporting staff of Kanti Children's Hospital and Ishan Children and Women's Hospital, who were involved in the treatment of our patients. We would also like to thank Dr. Rajendra Bohara and Dr. Santosh Gurung, World Health Organization, Programme for Immunization Preventable Diseases, Nepal for their support of our study.
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