British Medical Journal
01 December 2012 (Vol 345, Issue 7885)
http://www.bmj.com/content/345/7885

Head to Head
Should India launch a national immunisation programme against rotavirus? Yes
BMJ 2012; 345 doi: http://dx.doi.org/10.1136/bmj.e7818 (Published 30 November 2012)
Cite this as: BMJ 2012;345:e7818
Johnie Rose, senior instructor 1; Umesh D Parashar, medical epidemiologist2

Extract
India is considering including rotavirus vaccine in its national childhood immunisation programme. Johnie Rose and Umesh Parashar support the move, but Jacob Puliyel and Joseph Mathew (doi:10.1136/bmj.e7832) question the evidence used to support vaccination

The World Health Organization recommends inclusion of rotavirus vaccination of infants into all national immunisation programmes, with a strong recommendation for introduction of vaccine in countries like India where diarrhoeal deaths account for ≥10% of child mortality.1    The health burden of rotavirus in India is well established. WHO estimated that 98 621 Indian children died from rotavirus gastroenteritis in 2008, representing about one third of deaths from diarrhoeal disease and 4% of all child deaths in India.2 More recent data from the Million Death  Study, a nationally representative survey of 1.1 million Indian households, estimated that the virus causes 113 000 deaths a year.3 Both of these figures are conservative compared with an estimate of 147 000 annual rotavirus deaths obtained by directly extrapolating rates of laboratory confirmed rotavirus mortality from a contemporary community based birth cohort study in India.4

Non-fatal rotavirus gastroenteritis results in around 880 000 hospital admissions and 1.26 million …

Head to Head
Should India launch a national immunisation programme against rotavirus? No
BMJ 2012; 345 doi: http://dx.doi.org/10.1136/bmj.e7832 (Published 30 November 2012)
Jacob M Puliyel, consultant paediatrician1,
Joseph L Mathew, associate professor2

Extract
India is considering including rotavirus vaccine in its national childhood immunisation programme. Johnie Rose and Umesh Parashar (doi:10.1136/bmj.e7818) support the move, but Jacob Puliyel and Joseph Mathew question the evidence used to support vaccination

The programme to immunise all the world’s children with the rotavirus vaccine is based on mistaken assumptions. Careful evaluation of available evidence does not support the launch of the programme in India. It will divert funds from more life saving interventions and could cause harm.

Inappropriate extrapolations
The World Health Organization recommended universal rotavirus vaccination well before regional evidence of its effectiveness was collected. This is a distortion of the standard procedure whereby recommendations are made based on local evidence. The distortion came about in two stages. In 2007, the WHO committee looking at rotavirus vaccination for developing countries decided that efficacy data from one population can be extrapolated to other populations that are in an “equivalent child mortality strata.”1 This presumes that the prevalent virus strains are the same in different regions with similar socioeconomic status and mortality rates. There is no scientific evidence to support this assumption. Following this in 2009, using data from Malawi (one of the poorest regions in the world),2 Nicaragua, and a handful of developed countries, WHO recommended rotavirus vaccine for all regions of the world.3

Rationale

According to the GAVI Alliance, which funds vaccination for children in poor countries, rotavirus…