Introducing ROTAVAC® to the occupied Palestinian Territories: Impact on diarrhea incidence, rotavirus prevalence and genotype composition.

BACKGROUND: Rotavirus infection remains an important cause of morbidity and mortality in children. The introduction of vaccination programs in more than 100 countries has contributed to a decrease in hospitalizations and mortality. This study investigates the epidemiological impact of the rotavirus vaccine ROTAVAC® in the Palestinian Territories, the first country to switch from ROTARIX® to this new vaccine. METHODS: Clinical surveillance data was collected fromchildren younger than 5attendingoutpatient clinics throughout Gaza withdiarrhea between 2015 and 2020. The incidence of all-cause diarrhea was assessed using an interrupted time-series approach. Rotavirus prevalence was determined at the Caritas Baby Hospital in the West Bank usingELISA on stool specimen of children younger than 5with diarrhea. Genotyping was performed on 325 randomly selected rotavirus-positive samples from January 2015 through December 2020 using multiplex PCR analysis. RESULTS: Average monthly diarrhea casesdropped by 16.7% annually fromintroduction of rotavirus vaccination in May 2016 to the beginning of the SARS-CoV-2 epidemic in March 2020 for a total of 53%. Case count declines were maintained afterthe switchto ROTAVAC® in October 2018. Rotavirus positivity in stool samples declined by 67.1% over the same period without change followingthe switch to ROTAVAC®. The distribution of predominant genotypes in rotavirus-positive stool samples changed from a pre-vaccination G1P [8] to G9P[8] and G12P[8] during the ROTARIX® period and G2P[4] after the introduction of ROTAVAC®. CONCLUSION: ROTAVAC® has shown epidemiological impact on par with ROTARIX® after its introduction to the national immunization schedule in the Palestinian Territories. A molecular genotype shift from a pre-vaccination predominance of G1P[8] to a current predominance of G2P[4] requires more long-term surveillance.

Assessment of the surveillance system for adverse events following immunisation in the Gaza Strip: a cross-sectional study.

BACKGROUND: In the occupied Palestinian territory, the expanded programme on immunisation (EPI) has successfully targeted 13 diseases through vaccination and achieved high population coverage. However, surveillance of adverse events following immunisation (AEFI) is inadequate in the Gaza Strip, as only post-BCG lymphadenitis is reported. This study assessed the adherence of health-care workers (HCWs) to the AEFI surveillance system in the Gaza Strip. METHODS: Data were collected by four methods: 105 HCWs answered a questionnaire; 24 health facilities completed a checklist enquiry; 17 medical health officers and information system managers from Ministry of Health (MOH) and UNRWA health centres and hospitals underwent in-depth interviews; and a focus group was held with 22 epidemiologists, stakeholders, consultants, and managers of the EPI. The 24 health facilities comprised seven MOH primary health-care centres (PHCs) providing vaccination, five MOH PHCs not providing vaccination, seven UNRWA PHCs, and the five hospitals of the Gaza Strip with paediatric departments. Data collected from June, 2015, to August, 2015, were analysed with SPSS version 19. Relationships among variables were assessed by independent t tests, chi squared tests and one-way ANOVA. Verbal informed consent was obtained from all participants, and written approval for the study was obtained from MOH and UNWRA directorates. FINDINGS: AEFI are reported infrequently; approximately half of the 105 HCWs (51%; 53) report AEFI, but there were conflicting views as to whom they should report. 65% (68) thought that they should report all AEFI. Participants' educational background, participation in workshops, and number of years of employment affected AEFI recognition and reporting. The majority (74%; 78) participate in immunisation workshops. There is an ineffective structure in MOH centres, and the UNRWA has a well-established internal system for reporting AEFI but a poor system for external reporting to the MOH epidemiology department. A lack of HCW awareness of responsibilities may also have a role. The majority of HCWs (95%; 100) reported a need for further training, and all reported a lack of cooperation or coordination between hospitals and PHCs regarding AEFI notification. All individuals (17) who were interviewed knew that they must report AEFI. A majority (65%; 11) stated no difficulties, whereas some (35%; six) reported difficulties due to absence of guidelines, protocols, or notification forms, and to fear of punishment. Focus group participants felt that all AEFI should be reported. They agreed that HCWs face obstacles such as fear of consequences, lack of knowledge and training, high workloads, not considering AEFI as related to immunisation, and absence or shortage of notification forms, protocols, and guidelines. Some felt that certain AEFI should be reported only to treating doctors, but all agreed that there is no cooperation or coordination among PHCs and between hospitals and PHCs regarding AEFI reporting. INTERPRETATION: Common themes may explain poor adherence of HCWs to AEFI surveillance. The system is ineffective in MOH centres, and UNRWA PHCs have well-established internal but poor external reporting systems. Absence of monitoring may have a role, and a lack of guidelines, protocols, and forms for reporting were mentioned by HCWs, medical health officers and information system managers, and the focus group. Some HCWs may not know their responsibilities (eg, to whom AEFI should be reported). Many other obstacles face HCWs, including fear of punishment and accountability. Therefore, HCWs must be encouraged to report adverse events without fear of penalty. In addition, lack of education on AEFI and lack of experience in identifying AEFI may affect reporting. Training of HCWs, development of guidelines and protocols, database construction and design, and monitoring of the AEFI surveillance system are highly recommended. FUNDING: WHO EMRO.