IntroductionDiarrhoea remains a leading cause of child morbidity and mortality. Systematically collected and analysed data on the aetiology of hospitalised diarrhoea in low-income and middle-income countries are needed to prioritise interventions.MethodsWe established the Global Pediatric Diarrhea Surveillance network, in which children under 5 years hospitalised with diarrhoea were enrolled at 33 sentinel surveillance hospitals in 28 low-income and middle-income countries. Randomly selected stool specimens were tested by quantitative PCR for 16 causes of diarrhoea. We estimated pathogen-specific attributable burdens of diarrhoeal hospitalisations and deaths. We incorporated country-level incidence to estimate the number of pathogen-specific deaths on a global scale.ResultsDuring 2017–2018, 29 502 diarrhoea hospitalisations were enrolled, of which 5465 were randomly selected and tested. Rotavirus was the leading cause of diarrhoea requiring hospitalisation (attributable fraction (AF) 33.3%; 95% CI 27.7 to 40.3), followed by Shigella (9.7%; 95% CI 7.7 to 11.6), norovirus (6.5%; 95% CI 5.4 to 7.6) and adenovirus 40/41 (5.5%; 95% CI 4.4 to 6.7). Rotavirus was the leading cause of hospitalised diarrhoea in all regions except the Americas, where the leading aetiologies were Shigella (19.2%; 95% CI 11.4 to 28.1) and norovirus (22.2%; 95% CI 17.5 to 27.9) in Central and South America, respectively. The proportion of hospitalisations attributable to rotavirus was approximately 50% lower in sites that had introduced rotavirus vaccine (AF 20.8%; 95% CI 18.0 to 24.1) compared with sites that had not (42.1%; 95% CI 33.2 to 53.4). Globally, we estimated 208 009 annual rotavirus-attributable deaths (95% CI 169 561 to 259 216), 62 853 Shigella-attributable deaths (95% CI 48 656 to 78 805), 36 922 adenovirus 40/41-attributable deaths (95% CI 28 469 to 46 672) and 35 914 norovirus-attributable deaths (95% CI 27 258 to 46 516).ConclusionsDespite the substantial impact of rotavirus vaccine introduction, rotavirus remained the leading cause of paediatric diarrhoea hospitalisations. Improving the efficacy and coverage of rotavirus vaccination and prioritising interventions against Shigella, norovirus and adenovirus could further reduce diarrhoea morbidity and mortality.

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Rotavirus gastroenteritis is a major public health concern globally, estimated to cause 215,000 deaths among children < 5 years of age in 2013; with majority of mortality occurring in developing countries. In 2013, it was estimated that Nigeria was the second country with the highest number of rotavirus deaths. Monitoring of circulating rotavirus strains in Enugu, Nigeria is part of ongoing rotavirus surveillance before the introduction of rotavirus vaccination. A total of 2694 stool samples were collected from enrolled under 5 years old children with diarrhoea between January 2011 and December 2016 and tested the virus using an antigen enzyme immunoassay. Randomly selected rotavirus positive samples were further characterized by rotavirus genotype methods to identify the G and P types circulating during the study period. Rotavirus was detected in 1242 (46%) of the 2694 samples collected over the six years period. Of these, 867 were randomly selected for genotyping. G and P types could be assigned for 832 samples (96%), while 31 (3.6%) could only #

Background: The South African Expanded Programme on Immunisation (EPI-SA) currently vaccinates against 10 childhood vaccine preventable diseases. Six injections are required for primary vaccination against diphtheria, tetanus, pertussis, polio, Haemophilus influenza type b and hepatitis B: three DTaP-IPV//Hib [Pentaxim ® ] doses and three monovalent Hep B vaccines to children under 12 months of age, with a seventh injection (Pentaxim ® booster) at 18 months. Madhi et al (PIDJ 30:e68 2011) demonstrated no significant difference in the safety and efficacy between Pentaxim ® plus monovalent Hep B and a new fully liquid hexavalent vaccine, Hexaxim ® (DTaP-IPV-Hib-HepB). From a healthcare provider perspective, combination vaccines could reduce costs, simplify logistics and delivery infrastructure, and improve coverage with fewer injections. This study aimed to analyse the cost implications of a switch from the current combination of Pentaxim ® plus monovalent Hep B injections, to a single Hexaxim ® injection, from the public sector perspective. Methods & Materials: Data were collected to derive direct costs, i.e. vaccines' prices (except Hexaxim ® , no price yet available), transportation charges, cold chain storage, vaccine wastage rate, hazardous waste disposal and vaccine administration. All costs were calculated per dose, and expressed in South African Rand (R) (USD 1.00 = R10.19 per 2013 exchange rate). Indirect costs such as individual and societal benefits were excluded. Results: Delivering one dose ofPentaxim ® and Hep B costs R166.30. Reduced volumes result in cost reductions when using Hexaxim ® for: cold storage; hazardous waste disposal; and vaccine administration, resulting in an estimated saving of R10.52 to R29.40 per dose, depending on utilisation of usable cold storage space. Conclusion: Implementation of Hexaxim ® within EPI-SA is highly recommended, because it reduces healthcare provider costs by simplifying logistics and delivery infrastructure. From a community perspective, such vaccines reduce clinic visits, vaccinators' errors, number of injections and side effects, which translate to better acceptability, convenience and increased compliance. As the use of Hexaxim ® demonstrates direct and indirect cost savings, potential public sector introduction should be valued not only in terms of the price of Pentaxim ® and Hep B.

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