Rotavirus surveillance data reporting period: January - December 2011 1

Global Rotavirus Information and Surveillance Bulletin Volume 6: October 2012

Reporting period: January to December 2011

The Global Rotavirus Information and Surveillance Bulletin is produced by the World Health Organization (WHO) twice a year to share activities and data from the WHO-coordinated global surveillance network with partners at the national, regional and global levels.

Comments on this bulletin are welcome. Please Email to Dr. Mary Agócs (agocsm@who.int) To subscribe for the bulletin please send an email to vpdata@who.int

Table of Contents Page

Spotlight on:

Update on Activities from the Global and Regional Reference Laboratories o AFR RRL: MENDUSA, Pretoria, South Africa o EMR RRL: NAMRU-3, Cairo, Egypt o EUR RRL: Republican Research and Practical Center for Epidemiology

and Microbiology, Minsk, Belarus o WPR RRL: Murdoch Children’s Research Institute, Melbourne, Australia o GRL: Centers for Disease Control and Prevention, Georgia, USA

The 2012 Global Laboratory External Quality Assurance (EQA) Programme

1 2 3

4 5 5

Summary of January through December 2011 Rotavirus Surveillance Data 6

Annex: January through December 2011 Rotavirus Surveillance Data 7

The Global Surveillance Network for Rotavirus 7

Rotavirus Detection 8

Rotavirus Detection in Member States that have Introduced Rotavirus Vaccine 11

Genotype Data 12

WHO Rotavirus Regional Reference Laboratories and Other Laboratories Reporting Genotype Data

16

Surveillance Data Reporting Calendar, WHO Rotavirus Surveillance Websites and Acknowledgements

17

Spotlight on an Update from the Global and Regional Reference Laboratories:

WHO invited RRLs to share a short summary of main activities in support of the rotavirus surveillance network. The reports provided by RRLs are reproduced in this section to illustrate their important contribution to the network. The complete list of GRLs and RRLs with countries served is on page 16.

RRL: WHO AFR Summary report on Rotavirus Activities during 2011-2012 at the Rotavirus Regional Reference Laboratory (RRL) for AFR: MEDUNSA, Pretoria, South Africa

Photo: Workshop at RRL MENDUSA

Rotavirus surveillance data reporting period: January - December 2011 2

WHO/AFRO and the Rotavirus Regional Reference Laboratory (RRL) in South Africa / MRC Diarrhoeal Pathogens Research Unit (DPRU) continue to support rotavirus surveillance in Africa.

The RRL with support from WHO/AFRO organised the 11th African Region Rotavirus Surveillance Network (AFR RSN) genotyping workshop from 6 to 17 June 2011 at the University of Limpopo Medunsa Campus, Pretoria, South Africa. The WHO Representative, South Africa, Dr Stella Anyangwe, officially opened the workshop. She paid tribute to MEDUNSA for continued support to rotavirus surveillance in Africa and emphasized the importance of sentinel surveillance in supporting decision making on rotavirus vaccine introductions. The key objective of the workshop was to generate data on the circulating rotavirus strains in Africa using the WHO generic protocol and regional guidelines and variety of molecular techniques which included PAGE, RT-PCR and genotyping assays. A total of 17 participants from 15 African countries (Cote d’Ivoire, Democratic Republic of the Congo, Ethiopia, Guinea Bissau, Kenya, Mauritius, Nigeria, Senegal, South Africa, Togo, Tanzania, Uganda, Zambia, Zanzibar and Zimbabwe) were trained and subsequently analysed samples from their countries. A total of 778 samples were genotyped and the distribution of the strains showed that P[8]G1 (18.8%) were the most common strains detected, followed by P[8]G9 (9.8%), P[4]G2 (9.6%), P[6]G2 (8.6%), P[8]G12 (5.9%) and P[6]G1 (5.4%). Worldwide prevalent genotypes such as the P[8]G1, P[4]G2, P[8]G4 and P[8G9] represented 38.5% of all the samples typed at the AFR RSN genotyping workshop. The mixed genotype infections and partially typed (either G or P- types) were also found in 15.8% and 6.1% of samples, respectively (Figure A.) Figure A: Distribution of circulating rotavirus strains in African countries that participated at the 11th AFR RSN genotyping workshop 2011.

RRL: WHO EMR Summary report on Rotavirus Activities during 2011-2012 at the Rotavirus RRL for EMR: NAMRU-3, Cairo, Egypt NAMRU-3 serves as the WHO rotavirus RRL within EMRO. In these capacities, NAMRU-3 receives, processes and provides quality EIA testing and characterization of rotavirus strains by genotyping tools for both the VP7 and VP4 loci of the rotavirus genome. NAMRU-3 reports EIA and genotyping results from rotavirus testing through the WHO to host countries. In addition, NAMRU-3 assists the WHO by providing countries lacking these advanced diagnostic capabilities with training workshops for genotypic characterization and DNA sequencing of rotavirus strains. The activities over the years 2011 and 2012:

1- Sudan: 27 June 2011: The RRL received 465 stool samples collected at 3 sentinel sites in Sudan. In total, 462 samples (positive and negative) (99.4%) had congruent EIA results in both sides. The 358 rotavirus-positive samples were genotyped using the CDC G and P testing procedure. The variation in rotavirus genotype was observed in different sites. Twenty nine (8%) samples were untypeable for VP7 and VP4. By sequencing, the percentage of the untypeable

G1P[8]19%

G2P[4]10%

G3P[8]0%

G4P[8]0%G9P[8]

10%

Uncommon strains39%

Mixed G and P16%

Partially typed 6%

Photo: Workshop at RRL MENDUSA

Rotavirus surveillance data reporting period: January - December 2011 3 Photo: RRL Minsk

samples was reduced to 2% (n= 8). Mixed infection was common in SDGG, and [P4] G2 was the most common genotype in the three sites.

- 17 January 2012: In total, 630 stool samples were received from Sudan representing four sentinel sites, and 516 cases (82.0%) had congruent in EIA results. Additionally, the percentage of congruent EIA results varied between sites from 75% to 94% with an average of 88%. Overall, 491 rotavirus-positive samples representing all 4 sites were genotyped. The distribution of rotavirus genotypes varied between sites. Importantly, group of specimens showed a very high prevalence of mixed rotavirus infections in 81.0% (n=396/491) of the tested samples. [P6] G3 was the dominant genotype identified (96.5%; n= 469) in the tested samples; it was detected as a sole pathogen in 83 samples (16.9%) and as a co-pathogen in 386 samples (78.6%).

2- Afghanistan June 2012: 968 stool samples were received from Afghanistan. All the samples were tested using the EIA with the 87% of congruent in both sides. The genotyping testing for 781 positive samples was achieved. The analysis for the results and the sequencing for the untypable samples are on-going.

3- Iraq: July 2012: 2500 stool samples were received. The EIA testing for 10 % of the positives and 5% of the negatives is on-going. RRL: WHO EUR Summary report on Rotavirus Activities during 2011-2012 at the Rotavirus RRL for EUR: Republican Research and Practical Center for Epidemiology and Microbiology, Minsk, Belarus Since 2009, the RRL for the WHO European Region has been located in the Republican Research and Practical Center for Epidemiology and Microbiology in Minsk, Belarus. The WHO Rotavirus Regional Laboratory Network includes 7 National Laboratories (Armenia, Azerbaijan, Georgia, Moldova, Tajikistan and two laboratories in Ukraine). Close collaboration has been established with National Laboratory Coordinators from all countries and in 2012 the RRL also received samples for testing from Kyrgyzstan. The RRL provides external quality control for National Laboratories. In total, 1,161 ELISA tests were performed for samples collected in 2011 and 150 tests – for samples, collected in Q1 and Q2 2012. The concordance rate in 2011 was 97%. The RRL performed genotyping of 785 rotavirus samples collected in 2011 in Azerbaijan (68 specimens), Armenia (98), Georgia (84),

Kyrgyzstan (104), Moldova (98), Tajikistan (100), Ukraine, Kiev (65), Ukraine, Odessa (100) as well as 68 samples collected in the infectious diseases hospital in Minsk.

In 2011 and 2012 the RRL participated in proficiency testing arranged by the Global Reference Laboratory (CDC, Atlanta). The RRL also provided 3-days of hands-on training on rotavirus diagnostics for a virologist from

Photo: Rotavirus surveillance regional meeting, Minsk, 2010

Photo: Visit of GRL at RRL Minsk

Rotavirus surveillance data reporting period: January - December 2011 4

Photo: RRL Training at China CDC RRL

Moldova in February, 2012. An RRL rrepresentative participated in site assessment visits to Odessa and Kiev (Ukraine) and Baku (Azerbaijan) in 2012. The RRL participates in the annual Rotavirus Surveillance Meeting for NIS countries arranged by the WHO Regional Office for Europe (2010: in Minsk, Belarus; 2011: Lvov, Ukraine; 2012: in Kiev, Ukraine) to present RRL data and discuss future activities of the Regional Rotavirus Laboratory network.

RRL: WHO WPR

Summary report on Rotavirus Activities during 2011-2012 at the Rotavirus RRL for WPRO: Murdoch Children’s Research Institute, Melbourne, Australia

1. WHO Training and Onsite visits. a) Regional Laboratory Training Course on Rotavirus Detection and Strain Characterization, 25-29th July, 2011.Chungcheongbuk-do, Korea Presented lectures to participants at the intercountry hands-on training workshop on rotavirus detection and strain characterisation, and led the laboratory training components for PCR genotyping techniques and evaluation.

b) WHO Mission: Hanoi and Ho Chi Minh City, Vietnam, 14-21st March 2012. Together with Dr Fem Paladin (WPRO) conducted an evaluation of the performance and practices of the Enterovirus Laboratories at the National Institute of Hygiene and Epidemiology (NIHE) in Hanoi and the Pasteur Institute in Ho Chi Minh City with respect to undertaking rotavirus antigen testing and genotyping for the rotavirus surveillance program.

2. Rotavirus G & P Genotyping analysis The RRL based at MCRI in Australia received 680 faecal specimens for analysis during the activity period. Of these 188 were for genotype analysis, and 492 were for validation and evaluation of EIA and genotyping results. The 188 rotavirus positive faecal specimens for genotype analysis were collected from children with acute diarrhoea in 2 countries during 2011 – Fiji (132) and Papua New Guinea (56). Genotype analysis involved determination of rotavirus G and P genotype using hemi-nested multiplex RT-PCR assays.

Fiji specimen analysis

All of the 80 samples were assayed and confirmed as rotavirus, and analysed for rotavirus G and P genotype using RT-PCR analysis. P[8]G1 was the dominant type identified in 79 of the samples. A single P[4]G2 was identified. In addition 52 untested diarrhoeal samples were forwarded to the RRL for antigen detection and genotype analysis. Of these, 34 were found to be rotavirus negative. Genotype analysis was conducted on the remaining 18 rotavirus positive samples and revealed all as P[8]G1 rotavirus strains.

Verification of 111 rotavirus negative samples from Fiji was undertaken. Of these 95 were confirmed as rotavirus negative. An agreement rate of 85%. The 11 rotavirus positive samples were genotyped as: P[8]G1 – 7; P[4]G2 – 2; Mix – 1; P[8]Gnt – 1.

Papua New Guinea specimen analysis A total of 56 rotavirus positive faecal specimens were collected for analysis. All were genotyped with P[8]G3 as the dominant type identified, representing 41% of the samples characterized. P[4]G2 was the second most prevalent type identified, representing 21% of strains, with 3 P[8]G1 and a single P[4]G1 identified. Eleven samples contained a mixed G or P type, with 6 samples G or P non-typeable.

Rotavirus surveillance data reporting period: January - December 2011 5

Photo: Visit of GRL at SEAR RRL in Vellore, India, 2012

Vietnam specimen analysis The RRL conducted a verification and evaluation of rotavirus genotype analysis on 381 faecal specimens collected from children with acute diarrhoea in Vietnam during 2011. These constituted 247 rotavirus positive samples and 134 rotavirus negative samples. Rotavirus detection was compared by antigen detection using ProspecT ELISA assay. Verification of the rotavirus negative samples was conducted on 134 samples, of which 127 were found to be rotavirus negative. This constitutes an agreement of 95%. The 7 samples identified as rotavirus positive all contained P[8]G1 strains. A comparison of G and P genotype results was undertaken using hemi-nested multiplex RT-PCR assays on 247 samples. Comparative analysis of results are ongoing.

3. WHO Technical Working Group for the Rotavirus Surveillance Laboratory Network Dr Kirkwood is a member of the WHO technical working group for Rotavirus surveillance which provides WHO with technical guidance needed to strengthen laboratory capacities within the Global Rotavirus Network, improve the quality of genotyping data, standardize lab methods and advise on other laboratory issue as required.

4. Meeting participation a) Global Surveillance Meeting for Invasive Bacterial Diseases (IBD) and Rotavirus 12-14th September, 2011, Geneva, Switzerland. b) WPRO Regional workshop on surveillance for new vaccine preventable diseases and multiyear planning for national immunization programs. 30th Nov. - 2nd Dec., 2011, Manila, Philippines. GRL: WHO

Summary report on Rotavirus Activities during 2011 at the Rotavirus Global Reference Laboratory, CDC, Atlanta, USA Two investigators, one each from regional reference labs in Brazil and China, were trained on rotavirus characterization methods during 2011. GRL staff conducted two lab assessments using a new checklist developed during 2011 by GRL and WHO staff, and participated in two rotavirus training workshops during the first half of 2012 at the AFRO and SEARO Regional Reference Laboratories in Pretoria, South Africa and Vellore, India, respectively. About 700 rotavirus samples from 6 countries of the

Americas and African regions were genotyped during 2011 and the first half of 2012. EQA proficiency testing (PT) panels were shipped to WHO regional reference laboratories and referee laboratories in 11 countries in 2011, the results were scored after reports were submitted to CDC and reported to RRL or referee laboratories within 30 days. PT testing for 2012 is underway. In 2011, the GRL completed the development of an NSP3 real time RT-PCR primer/probe kit and shipped 2 of these kits and 8 genotyping primer kits to laboratories in 10 countries of the Global Rotavirus Lab Network. The GRL conducted research on new rotavirus genotyping methods and stability of PT panels at different temperatures during 2011, and started developing lyophilized PT panels in 2012.

Spotlight on the 2012 Global Laboratory External Quality Assurance (EQA) Programme:

The WHO coordinated and supported global EQA programme was launched in 2011 with the GRL at the U.S. Centers for Disease Control and Prevention as implementing entity. During 2012, the GRL provided standard proficiency testing panels of simulated stool specimens to each WHO RRL via dry ice shipment to validate proficiency panels. Each RRL performed diagnostic testing including genotyping, and provided results to the GRL. To date, 9 of the 10 RRLs passed the

Rotavirus surveillance data reporting period: January - December 2011 6

EQA to identify the presence of the rotavirus, and similarly 9 of the 10 RRLs were able to accurately genotype the virus. WHO envisions to extend the EQA programme to include national laboratories and hospital sentinel sites during 2013, based on the outcomes of on-going research at the GRL to determine if ‘lyophilized’ (e.g. freeze dried) panels can be shipped at room temperature. Summary of January through December 2011 Rotavirus Surveillance Data

This Bulletin presents surveillance data for January through December 2011, as reported by Member States participating in the WHO-coordinated global surveillance network for rotavirus. Data are collected through sentinel surveillance of children < 5 years of age who are hospitalized for treatment of acute gastroenteritis/diarrhoea. Summarized below are the main findings from January through December 2011:

Member States reporting surveillance data (clinical or genotype) 64 Member States reported data, either clinical or genotype information 43 of 64 (67%) reporting countries were GAVI-eligible

Rotavirus Vaccine Introduction1

2006: Brazil, El Salvador, Nicaragua, Panama, Venezuela (Bolivarian Republic of) 2007: Ecuador, Peru 2008: Bolivia (Plurinational State of), Mexico, South Africa 2009: Colombia, Honduras 2010: Guatemala, Guyana, Morocco, Paraguay 2011: Sudan

Annual rotavirus detection:

58 Member States reported rotavirus clinical surveillance data to WHO from 185 sentinel sites Of these, 42 (72%) countries reported at least 100 cases and reported the number of stool

specimens tested for all 12 months. The latter required to account for seasonal disease variation. Data from these 42 countries were thus used to calculate rotavirus detection.

Global median rotavirus detection (among 42 countries): 36% By WHO Region:

Highest: Western Pacific Region (53%) Lowest: Region of the Americas (20%)

By country: Highest: Democratic Republic of the Congo (65%) Lowest: Chile (9%) Note: Twelve of the 14 countries that introduced rotavirus vaccine into their national immunization schedule before or during 2011 were based in the Region of the Americas. Guyana and Nicaragua were excluded from calculation of global and regional medians because Nicaragua did not report cases every months for rotavirus and Guyana tested <100 specimens. In addition Panama was excluded from the calculations as the country only reports on the positive cases for rotavirus.

1 Rotavirus vaccine included in National Immunization Schedules. South Africa, Mexico and Peru are reporting genotype data only.

Rotavirus surveillance data reporting period: January - December 2011 7

Annex: January through December 2011 Rotavirus Surveillance Data

The Global Surveillance Network for Rotavirus

During 2011, 64 WHO Member States participated in the global rotavirus surveillance network (Figure 1, Table 1). Seventy percent of these countries were based in three (3) WHO Regions: AFR, AMR and EMR. Overall, 43 participating countries (67 %) were eligible for GAVI funding. Among the 58 countries reporting clinical data in 2011, the following countries joined the rotavirus reporting network in 2011: Central African Republic, Niger and Nigeria from AFR, Bolivia (Plurinational State of) and Nicaragua from AMR, Jordan from EMR. Some countries did not report data in 2011: Egypt, Iran, Libya, Oman and Tunisia from EMR. This left a net gain of 1 country that reported clinical data and was included in the network in 2011 compared to 2010. Globally, 48,947 children who were hospitalized for the treatment of acute gastroenteritis/diarrhoea were enrolled in the WHO rotavirus surveillance network (Table 2).

Figure 1. WHO Member States that reported to the global rotavirus surveillance network from January – December 2011.

Rotavirus surveillance data reporting period: January - December 2011 8

Rotavirus Detection Rotavirus detection was calculated as the percent of stool specimens positive for rotavirus among specimens tested. Panama was excluded as information was reported only for cases with positive specimens. Figure 2 displays these percentages by month, country and WHO Region for 2011. SEAR countries are not listed as the number of tested specimens was only provided annually.

WHO

Region*

Total number of

Member States

reporting

Number of GAVI-funded

Member States

reporting

% of all Member States

reporting who are GAVI-

funded

Total number of sentinel

sites reporting

AFR 19 17 89% 33

AMR 18 5 28% 81

EMR 8 4 50% 38

EUR 8 7 88% 9

SEAR 4 4 100% 6

WPR 7 6 86% 18

Total 64 43 67% 185

South Africa in AFR, Cuba, Mexico and Peru in AMR, Belarus and Kyrgyzstan in EUR are only reporting Genotype data.

*The follow ing Member States participated in the global surveillance netw ork for rotavirus from January through December 2011 :

Cameroon, Central African Republic, Côte d'Ivoire, Democratic Republic of the Congo, Ethiopia, Ghana, Guinea-Bissau, Kenya, Mauritius,

Niger, Nigeria, Rw anda, Senegal, Togo, Uganda, United Republic of Tanzania, Zambia and Zimbabw e in the African Region (AFR); Bolivia

(Plurinational State of), Brazil, Chile, Colombia, Ecuador, El Salvador, Guatemala, Guyana, Honduras, Nicaragua, Panama, Paraguay, Saint

Vincent and the Grenadines, Suriname and Venezuela (Bolivarian Republic of) in the Region of the Americas (AMR); Afghanistan, Iraq,

Jordan, Morocco, Pakistan, Sudan, Syrian Arab Republic, and Yemen in the Eastern Mediterranean Region (EMR); Armenia, Azerbaijan,

Georgia, Republic of Moldova, Tajikistan and Ukraine in the European Region (EUR); Indonesia, Nepal, Myanmar and Sri Lanka from the

South-East Asian Region (SEAR); Cambodia, China, Fiji, Lao People's Democratic Republic, Mongolia, Papua New Guinea and Viet Nam in

the Western Pacif ic Region (WPR).

Table 1: Characteristics of the global surveillance network for rotavirus, by WHO Region -

January-December 2011

WHO Region No. of children enrolled % of Total Range (by country)

AFR 9,288 19 50-1,133

AMR 11,763 19 7-2,215

EMR 10,775 22 239-5,865

EUR 8,220 17 537-2,015

SEAR 2,606 5 218-1,042

WPR 6,295 13 60-2,480

Total 48,947 100 7-5,865

Table 2. Number (No.) of children <5 years of age hospitalized for the treatment of

acute gastroenteritis/diarrhoea and enrolled in the WHO rotavirus surveillance

network, by WHO Region, January-December 2011

Rotavirus surveillance data reporting period: January - December 2011 9

Figure 2. Monthly rotavirus detection, by country and WHO region, 2011.

Figure 3 provides the annual rotavirus detection only for countries that tested at least 100 specimens and those countries that reported the number of stool specimens tested for all 12

Rotavirus Surveillance, 2011Rotavirus detection rate %

Tested Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

AFRCameroon 655 65 25 20 20 14 6 13 10 15 45 50 47

Central African Republic (the) 54 ND ND ND ND ND ND ND ND 0 0 67 64

Côte d'Ivoire 52 0 0 ND ND ND ND 50 63 ND 33 33 18

Democratic Republic of the Congo (the) 623 40 60 69 80 74 65 70 71 60 37 67 24

Ethiopia 523 20 7 12 9 7 7 6 3 12 23 58 48

Ghana 976 58 60 56 43 46 52 50 44 43 57 47 52

Guinea-Bissau 404 46 74 44 63 26 29 20 28 19 21 56 57

Kenya 830 31 41 46 24 20 10 27 55 37 31 6 23

Mauritius 235 20 53 32 21 6 29 33 56 50 73 53 53

Niger (the) 71 ND 0 ND 17 0 18 13 0 0 ND 67 25

Nigeria 314 78 67 70 38 40 13 0 0 0 0 40 58

Rw anda 240 22 0 0 50 46 56 57 49 55 47 54 ND

Senegal 129 58 55 64 0 ND 20 25 33 50 60 50 42

Togo 258 76 55 55 50 13 29 36 50 36 57 53 73

Uganda 1080 40 38 23 18 27 20 22 36 38 31 30 19

United Republic of Tanzania 254 27 23 34 41 15 56 29 76 0 ND ND 0

Zambia 1132 6 4 17 27 61 66 67 63 55 27 25 16

Zimbabw e 1011 11 7 0 0 53 69 62 23 19 5 19 26

AMRBolivia (Plurinational State of) 1456 10 1 5 8 30 62 63 47 30 48 32 30

Brazil 779 6 7 17 9 14 21 16 11 28 14 16 0

Chile 781 14 8 11 5 5 3 5 10 11 17 8 21

Colombia 571 10 20 15 29 30 25 7 2 2 0 0 0

Ecuador 1015 15 12 20 11 5 5 0 8 18 39 30 10

El Salvador 2132 9 10 26 46 47 40 24 22 27 15 25 47

Guatemala 2041 14 53 70 60 35 17 12 10 9 10 4 10

Guyana 24 ND ND ND ND ND ND ND ND ND ND ND ND

Honduras 2215 36 47 37 40 18 12 6 14 8 9 17 45

Nicaragua 125 ND ND ND ND ND 8 0 0 0 0 0 0

Paraguay 206 10 47 13 0 0 29 58 43 29 29 12 18

Saint Vincent and the Grenadines 7 ND 0 ND ND ND ND 100 ND ND 0 ND 0

Suriname 180 5 5 31 13 0 31 50 29 22 0 0 20

Venezuela (Bolivarian Republic of) 231 21 41 57 30 31 25 0 0 3 10 4 0

EMRAfghanistan 1153 48 56 55 52 61 71 29 40 65 74 89 82

Iraq 1386 54 47 72 54 45 24 39 48 75 57 81 66

Jordan 339 57 29 44 42 30 30 37 47 45 48 52 23

Morocco 208 63 39 55 13 22 37 33 62 35 33 0 0

Pakistan 1142 26 38 25 18 9 8 5 12 26 22 43 24

Sudan (the) 5049 45 38 59 59 44 27 21 17 16 27 63 48

Syrian Arab Republic (the) 239 0 41 44 ND 22 17 67 54 46 54 75 69

Yemen 320 33 21 25 11 0 12 8 15 8 29 23 33

EURArmenia 1824 60 57 57 41 35 24 21 8 13 20 40 54

Azerbaijan 1033 10 49 33 10 57 82 7 7 6 0 1 10

Georgia 537 0 39 33 40 24 16 7 9 9 0 14 25

Republic of Moldova 1107 66 65 72 70 44 39 17 30 23 38 24 58

Tajikistan 2015 39 50 13 28 24 33 48 38 50 52 33 20

Ukraine 1701 61 67 70 59 56 29 29 43 52 35 49 58

WPRCambodia 898 79 78 38 41 33 28 34 43 52 56 60 62

China 1713 54 47 22 24 27 20 15 17 23 42 60 44

Fiji 357 17 0 28 29 48 66 37 38 9 0 9 0

Lao People's Democratic Republic (the) 243 70 80 44 38 18 0 0 0 0 0 0 0

Mongolia 806 61 67 48 47 61 48 25 22 48 75 72 55

Papua New Guinea 55 ND 0 60 33 50 40 0 50 33 33 14 14

Viet Nam 1440 69 61 53 54 51 59 55 41 60 38 60 68

>= 40% of tested samples were positive for Rotavirus

>= 30% and < 40% of tested samples were positive for Rotavirus

>= 20% and < 30% of tested samples were positive for Rotavirus

>= 10% and < 20% of tested samples were positive for Rotavirus

< 0% of tested samples were positive for Rotavirus

ND No data available

Rotavirus surveillance data reporting period: January - December 2011 10

months to account for seasonal variation in rotavirus disease. For 2011, 42 out of 58 countries (72%) met these criteria.

NOTE: Countries with Rotavirus vaccine in National Immunization Schedules: 2006: Brazil, El Salvador, Venezuela (Bolivarian Republic of); 2007: Ecuador; 2008: Bolivia (Plurinational State of); 2009: Colombia, Honduras; 2010: Guatemala, Morocco and Paraguay; 2011: Sudan.

Median values as an entire region were calculated for 2011 (Figure 3). The median detection of rotavirus by region ranged from 20% in AMR to 53% in WPR. The global median was 36% in 2011. The percentage by country ranged from 9%-65% among the 42 countries meeting the two criteria.

Among the 42 countries meeting the two criteria and listed on Figure 3, the annual detection of rotavirus from January to December 2011 was also stratified by age group (Table 3). Among the 12 AFR countries, the median detection was highest among the two youngest age bands (0-5 months old [46%] and 6-11 months old [43%]). While in the other reporting Regions, median detection tended to be higher among children older than 5 months of age.

Table 3: Annual rotavirus detection rates, medians by age group and WHO region - 2011

WHO Region

No.of Member

States* 0-5months 6-11months 12-23months 24-59months All children < 5 years of age

AFR 12 46 43 36 30 40

AMR 11 25 20 20

EMR 7 32 41 45 28 39

EUR 6 25 32 41 32 37

WPR 6 33 55 52 33 53

Median detection rate (%)

18.8

*Member States meeting the criteria for inclusion in 2011 full-year analysis and reporting surveillance data by age group: Cameroon, Democratic Republic of the

Congo, Ethiopia, Ghana, Guinea-Bissau, Kenya, Mauritius, Nigeria, Togo, Uganda, Zambia and Zimbabw e in the African Region (AFR); Bolivia (Plurinational State of),

Brazil, Chile, Colombia, Ecuador, El Salvador, Guatemala, Honduras, Paraguay, Suriname and Venezuela (Bolivarian Republic of) in the Region of the Americas

(AMR); Afghanistan, Iraq, Jordan, Morocco, Pakistan, Sudan and Yemen in the Eastern Mediterranean Region (EMR); Armenia, Azerbaijan, Georgia, Republic of

Moldova, Tajikistan and Ukraine in the European Region (EUR); Cambodia, China, Fiji, Lao People's Democratic Republic, Mongolia and Viet Nam in the Western

Pacif ic Region (WPR).

% of stool specimens tested positive

Figure 3: Rotavirus Detection for the 42 Countries that Tested > 100 Stool Specimens and Reported the Number

of Specimens Tested and Tested Positive for Each Reporting Period Used by WHO Region, 2011

Rotavirus surveillance data reporting period: January - December 2011 11

Population-Based Surveillance Population-based surveillance data was reported to the WHO rotavirus surveillance network from the government of Kenya. For the denominator, information from the Kenya Medical Research Institute / Centers for Disease Control and Prevention was used to establish the 2011 population of children under 5 years of age in the Karemo and Gem catchment area. Rotavirus hospitalizations were included from Siaya District Hospital and Ting'wang'i/Njejra Health Facilities. Among the 25,258 children <5 years of age in the catchment area, 723 children were hospitalized with acute gastroenteritis (AGE) during 2011. Of these, 479 (66%) were enrolled into surveillance and had a stool specimen tested. The overall incidence rate of children hospitalized with AGE was 1,896 per 100,000 children <5 years of age. Of the 479 children with a stool specimen tested, 125 (26%) had rotavirus detected in their stool. The overall incidence of hospitalization due to rotavirus AGE was 495 per 100,000 children. However, this rotavirus incidence is based only on the 66% of children with a stool specimen tested, and is therefore a conservative underestimate. Among the 479 children with a tested specimen, 26% were positive for rotavirus. If this percentage is applied to all 723 children with diarrhea, then 188 children would have been expected to be positive, with a rate of 744 per 100,000.

Rotavirus Detection in Member States that have Introduced Rotavirus Vaccine

Summarizing country-specific trends of rotavirus detection before and after rotavirus vaccine introduction is a useful way to share information generated by this sentinel surveillance network. However, such summaries can produce misleading information due to data reporting artefacts. For example, sentinel sites may not report data every month, and including sentinel sites that only report during the high season of rotavirus detection can lead to erroneously high rotavirus detection summaries. Additionally, countries that introduce rotavirus vaccine target children <1 year of age. Thus, presenting surveillance data for all children <5 years of age may be misleading. WHO is working with partners including US CDC to identify parameters for summarizing sentinel site surveillance data, and is considering the best graphical display of the data. Thus, country specific rotavirus detection figures are not included in this bulletin; these figures will be presented in future bulletins.

Rotavirus surveillance data reporting period: January - December 2011 12

Genotype Data

In 2011, there was an increase in countries reporting genotype data from 20 countries in 2009 to 37 countries in 2010 and 38 in 2011. P[8]G1 was the predominant rotaviral serotype reported (Figures 4 and 5).

Figure 4. Percent Distribution of Rotavirus Genotypes among Specimens Typed, by Country and WHO Region, 2011. The number of genotyped specimens (n= ) stated next to the country.

The ten (10) genotypes listed in the graphs represent the 10 most prevalent reported in the 5 WHO Regions (SEAR data not available). The distribution of rotavirus genotypes detected in each WHO Region during 2010 and 2011 is shown in Figure 5. Detected genotypes differed widely by Region and by year.

Rotavirus surveillance data reporting period: January - December 2011 13

Figure 5. Distribution of Rotavirus Genotypes by WHO Regions, 2010 and 2011 2010 2011

13 countries included: Burkina Faso, Cameroon, Cote I’voire, DR Congo, Ethiopia, the Gambia, Kenya, Mauritius, Tanzania, Togo, Uganda, Zambia, Zimbabwe

16 countries included: Cote I’voire, DR Congo, Ethiopia, Ghana, Guinea Bissau, Kenya, Mauritius, Niger, Nigeria, Senegal, South Africa, Tanzania, Togo, Uganda, Zambia, Zimbabwe

5 countries included: Brazil, Guatemala, Honduras, Nicaragua, Suriname

5 countries included: Brazil, El Salvador, Guatemala, Honduras, Mexico

n=933 n=898

n=914 n=843

Rotavirus surveillance data reporting period: January - December 2011 14

2010 2011

2 countries included: Sudan, Syria

1 country included: Sudan

4 countries included: Azerbaijan, Georgia, Tajikistan, Ukraine

8 countries included: Azerbaijan, Armenia, Belarus, Georgia, Kyrgyzstan, Moldova, Tajikistan, Ukraine

n=702 n=498

n=970 n=468, additional data pending

Rotavirus surveillance data reporting period: January - December 2011 15

2010 2011

2 countries included: Indonesia, Myanmar, Nepal

4 countries included: Lao PDR, Mongolia, Papua New Guinea, Viet Nam

7 countries included: Cambodia, China, Fiji, Lao PDR, Mongolia, Papua New Guinea, Viet Nam

WPR

P[8], G1 P[4], G2 P[8], G3 P[8], G4 P[8], G9 P[6], G1

P[6], G2 P[6], G3 P[6], G4 P[6], G6 P[6], G8 P[6], G9

P[6], G10 P[6], G12 P[8], G 2 P[8], G 8 P[8], G12 P[4], G1

P[4], G3 P[4], G4 P[4], G8 P[4], G9 P[4], G12 P[9], G2

P[9], G3 P[9], G9 P[10], G1 P[10], G2 P[10], G3 P[10], G4

P[11], G9 P[12], G8 P[14], G8 Not specified Mixed Untypeable

n=271 n=Pending

n=1764 n=1677

Rotavirus surveillance data reporting period: January - December 2011 16

Table 4. WHO Rotavirus Regional Reference Laboratories and Other Laboratories Reporting Genotype Data, 2011

Region Name of Laboratory

Location Countries Served

African Region

(AFR)

Noguchi Institute for Medical Research, WHO Regional Reference Laboratory for Rotavirus

Ghana

Benin, Ghana, Liberia, Niger, Nigeria,

Sierra Leone

University of Limpopo Medunsa Campus, WHO Regional

Reference Laboratory for Rotavirus South Africa

Burkina Faso, Cameroon, Côte d'Ivoire,

Democratic Republic of the Congo (the), Ethiopia, Gambia (the), Kenya, Mauritius, South Africa, United Republic of Tanzania

(the), Togo, Uganda, Zambia, Zimbabwe

Region of the Americas

(AMR)

Centers for Disease Control and Prevention (CDC), WHO Regional Reference Laboratory for Rotavirus

Atlanta, USA

Guatemala, Honduras Nicaragua, Suriname

National Public Health Institute of Rio de Janeiro, Acting WHO Regional Reference Laboratory for Rotavirus*

Rio de Janeiro, Brazil

Brazil

Eastern

Mediterranean Region (EMR)

Naval Medical Research Unit No. 3 (NAMRU), WHO Regional Reference Laboratory for Rotavirus

Cairo, Egypt Sudan (the), Syrian Arab Republic (the)

European

Region (EUR)

Republican Research and Practical Center for Epidemiology

and Microbiology, WHO Regional Reference Laboratory for Rotavirus

Minsk, Belarus

Armenia, Azerbaijan, Belarus, Georgia,

Kyrgyzstan, Republic of Moldova, Tajikistan, Ukraine

South-East

Asia Region (SEAR)

Christian Medical College, WHO Regional Reference Laboratory for Rotavirus

Vellore, India

Myanmar, Nepal

Western Pacific Region

(WPR)

Murdoch Children's Research Institute (MCRI), Royal Children's Hospital, WHO Regional Reference Laboratory for Rotavirus

Melbourne,

Australia

Fiji, Mongolia, Papua New Guinea,

Philippines

Korea Centers for Disease Control and

Prevention (KCDC), WHO Regional Reference Laboratory for Rotavirus

Chungcheong

buk-do, Republic of

Korea

Cambodia, Lao Peolple's Democratic Republic (the), Mongolia

Institute for Viral Disease Control and Prevention, China Centers for Disease Control and Prevention, Nominated as WHO Regional Reference Laboratory for Rotavirus

Beijing, China China

Global Reference Laboratory

Centers for Disease Control and Prevention (CDC) Atlanta, USA Worldwide

*Brazil contributes genotype data to the WHO surveillance network, but are not currently categorized as WHO RRLs.

Rotavirus surveillance data reporting period: January - December 2011 17

Surveillance Data Reporting Calendar

The below reporting calendar is used for the surveillance network Reporting Frequency Site to national /regional WHO

At least Quarterly* January April July October

Site sends data from previous Oct-Dec to MOH and WHO CO**

Site sends data from previous Jan-Mar to MOH and WHO CO**

Site sends data from previous Apr-Jun to MOH and WHO CO**

Site sends data from previous Jul-Sept to MOH and

WHO CO**

Regional Reference Laboratory to WHO RO

6-Monthly Apr-May Oct-Nov

Annual data Jan-Dec of previous year Data from Jan-June of same year

Regions to countries (regional feedback bulletin)

Quarterly Jan Apr July Oct

RO prepares quarterly bulletin of country data from

Jul-Sept of previous year

RO prepares quarterly bulletin of country data

from Oct-Dec of previous year

RO prepares quarterly bulletin of country data from

Jan-Mar of previous year

RO prepares quarterly bulletin of country data from

Apr-Jun of previous year

Regions to WHO HQ (regional feedback bulletin)

6-Monthly July Nov

WHO RO sends aggregate regional data from Jan-Dec of the previous year to WHO HQ. These

data include genotype results from regional reference laboratories***

WHO RO sends regional data from Jan-Jun of previous year to WHO HQ

HQ to regions (global bulletin)

6-Monthly Oct Feb

WHO HQ drafts a global bulletin with data from Jan-Dec of the previous year to the regions which

includes genotype information***

WHO HQ drafts bulletin with data from Jan-June of the previous year to the regions

*Many sites are currently reporting to WHO monthly and this should be continued. Quarterly reporting is the minimum accepted and monthly reporting is preferred. **MOH - Ministry of Health, CO - country office, RO - Regional office (in AFRO this may be sub-regional office)

***Although regional reference laboratories should report genotype data to the regional office on a 6-montly basis this will only be shared with WHO HQ and the countries in the region annually

WHO Rotavirus Surveillance Websites http://www.who.int/nuvi/surveillance/resources/en/index.html http://www.who.int/nuvi/rotavirus/en/index.html and http://www.who.int/nuvi/surveillance/en/ Acknowledgements WHO gratefully acknowledges the dedicated efforts of the numerous individuals and organizations involved with compiling this surveillance information, including Ministries of Health, sentinel hospitals, as well as the network of global, regional and national reference laboratories.