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Burden of Severe Rotavirus Diarrhea in

Indonesia1.  Yati Soenarto1,2. Abu. T. Aman2,3. Achirul Bakri 3,4. Herman Waluya3,5. Agu !irmanyah4,". #u$al %a&im4,'. (e)e #arti$a5,*. +i -raetyo5,. /enny S. #ulyani 1,10. Titi Wi&oati 1,11. Soet)iningih6,12. (. -utu e&e %aryana6,13. Wayan Sukar&i 7,14.  oeh Breee8 an&15. #arcAlain Wi&&oon8

Author Afliations1. Departments o 2. 1Child Health and3. 2Miro!iolo"#$ %ault# o Mediine$ &ad'ah Mada (ni)ersit#$ *ard'ito

Hospital$ +o"#a,arta$4. 3Department o -ediatris$ %ault# o Mediine$ *rii'a#a (ni)ersit#$

Muhammad Hussein Hospital$ -alem!an"$5. 4Department o -ediatris$ %ault# o Mediine$ (ni)ersit# o /ndonesia$

Cipto Man"un,usumo Hospital$ 0a,arta$6. 5Department o -ediatris$ -ad'a'aran (ni)ersit#$ Hasan *adi,in Hospital$

andun"$7. 6Department o -ediatris$ %ault# o Mediine$ (da#ana (ni)ersit#$

*an"lah Hospital$ ali$ and

8. 7Department o -ediatris$ %ault# o Mediine$ Mataram (ni)ersit#$Mataram Hospital$ Mataram$ /ndonesia and

. 8ational Center or /mmuniations and espirator# Diseases$ Centers orDisease Control and -re)ention$ Atlanta$ &eor"ia

1. eprints or orrespondene Dr. +ati *oenarto$ Dept. o Child Health$ %ault# o Mediine$&ad'ah Mada (ni)ersit#$ *ard'ito Hospital$ 0l. esehatan no. 1$ +o"#a,arta$ /ndonesia9#atisoenarto:#ahoo.om;

 e<t *etion

 Abstract

&lo!all#$ rota)irus is the leadin" ause o diarrhea=related hospitaliationsand deaths amon" #oun" hildren$ !ut the !urden o rota)irus disease in/ndonesia is poorl# doumented. %rom 0anuar# throu"h Deem!er 2>>6$ eonduted prospeti)e sur)eillane 9inpatient and outpatient; amon"hildren a"ed ?5 #ears at 6 hospitals in 6 pro)ines o /ndonesia$ usin"standardied methodolo"#. @ 224> enrolled hildren hospitalied ordiarrhea$ 1345 96>; ere rota)irus positi)e. @ 176 hildren enrolled inoutpatient linis in 3 hospitals$ 73 941; ere rota)irus positi)e. Amon"

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hildren hospitalied or diarrhea$ deh#dration as more ommon amon"those ho tested positi)e or rota)irus than amon" those ho did not 91)s 82 -?.>5;$ as as )omitin" 986 )s 67 -?.>5;. Children a"ed 6B23months e<periened 72 o all rota)irus episodes. ota)irus pre)aleneinreased sli"htl# in the ool$ dr# season. he most ommonl# deteted

"enot#pes ere & 93>; and -6E 956;. &1-6E and &-6E aounted or34 and 21 o strains$ respeti)el#. A hi"h proportion o "enot#pe -6E asdeteted$ in om!ination ith the ommon & t#pes &1 and &. A)aila!lerota)irus )aines ould li,el# !e efaious a"ainst the most ommonirulatin" strains$ !ut ontinued monitorin" o unommon "enot#pes isneeded

ota)irus is the leadin" ause o se)ere aute diarrhea inhildren throu"hout !oth de)eloped and de)elopin"ountries. F)er# #ear$ rota)irus is estimated to ause

G5>>$>>> deaths orldide amon" hildren a"ed ?5 #ears$ith G8> o these deaths ourrin" in de)elopin" nations1E. %urthermore$ rota)irus inetion auses 2.1 millionhospitaliations$ 25 million outpatient )isits$ and 111 millionepisodes o diarrhea orldide annuall# 2E. *ur)eillane orota)irus in se)eral ountries in the Asian re"ion has oundrota)irus to !e assoiated ith 3>B7> o diarrhea=relatedhospitaliations amon" hildren 3$ 4E/n /ndonesia$ e lon"itudinal studies on the !urden o

rota)irus disease ha)e !een onduted sine the 17>s 5B7E. hese older studies used )arious methodolo"ies and ma# nolon"er reet the etiolo"ies o aute diarrhea in /ndonesiatoda#. he annual num!er o diarrhea=related deaths amon"hildren in /ndonesia has dereased durin" the past 2> #ears$lar"el# !eause o the suessul use o oral reh#dration salt.%urthermore$ the inidene o !aterial "astroenteritis hasdereased !eause o impro)ements in sanitation$ h#"iene$and the a)aila!ilit# o anti!iotis$ hih ould ha)e had little

eIet on the rates o rota)irus inetion o redue the !urden o rota)irus "astroenteritis$ rota)irus)aines ha)e !een de)eloped and introdued or routineimmuniation in se)eral ountries in the Amerias andFurope. /n /ndonesia$ a la, o data on rota)irus !urden andirulatin" strains has led to poor reo"nition o the

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ma"nitude o the pro!lem and lo prioritiation o rota)irus)aines as a pre)ention strate"# 8E. o inorm a uturedeision a!out rota)irus )aine introdution in /ndonesia$ eonduted standardied sur)eillane or se)ere rota)irus

diarrhea and irulatin" rota)irus strains in 6 health areailities throu"hout /ndonesia as part o the Asian ota)irus*ur)eillane etor,-re)ious *etione<t *etion

Materials and Methods

 his stud# olloed "uidelines laid out in a "eneri protool or rota)irussur)eillane pu!lished !# the Jorld Health @r"aniation the protool asdesi"ned to standardie sur)eillane eIorts in diIerent ountries EPopulation and sample he stud# population onsisted o all hildren a"ed

?5 #ears ho presented ith aute diarrhea rom 0anuar# throu"h Deem!er2>>6 at an# o 6 teahin" hospitals. he partiipatin" hospitals are loated in6 diIerent pro)ines o /ndonesia$ on the islands o *umatra$ 0a)a$ ali$ andJest usa en""ara 9%i"ure 1;. he hospitals ere Muhammad HusseinHospital 9-alem!an"$ *outh *umatra;$ Cipto Man"un,usumo Hospital90a,arta$ Capital Cit# *peial erritor#;$ Hasan *adi,in Hospital 9andun"$Jest 0a)a;$ *ard'ito Hospital 9+o"#a,arta$ +o"#a,arta *peial erritor#-ro)ine;$ *an"lah Hospital 9Denpasar$ ali;$ and Mataram Hospital9Mataram$ Jest usa en""ara;

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!igure 1

Map o the hospital loations

InpatientsAll hildren a"ed ?5 #ears ho ere admitted to the partiipatin"hospitals ith a primar# dia"nosis o diarrhea ere sreened or stud#eli"i!ilit#. Aute diarrhea as deLned as 3 loose stools within 24 h and for a duration

of <2 weeks [1>E. A standardied linial orm as ompleted to o!tain detailedinormation on the date o admission$ a"e and se< o the patient$ nutritionalstatus$ pre)ious treatment$ status o deh#dration$ s#mptoms o illness$ andLnal dia"nosis. A resh eal speimen as o!tained rom enrolled hildrenithin 24 h ater admission$ as plaed in a lean ontainer$ and as storedat 4NCB8NC until la!orator# testin" or rota)irus

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OutpatientsChildren a"ed ?5 #ears ho reei)ed treatment at outpatientlinis or aute diarrhea 9as deLned a!o)e; in 1 o 3 partiipatin" hospitalsOHasan *adi,in Hospital$ *ard'ito Hospital$ and Mataram HospitalOereenrolled. A standardied linial orm similar to the one desri!ed a!o)e asompleted

%eal samples ere olleted at presentation !# a nurse or at home ithin 2da#s ater the lini )isit !# parents or areta,ers$ ho ere "i)en smallontainers or that purpose. *amples ere sent to the hospital immediatel#or ere ,ept in the reri"erator until the ne<t da#

Laboratory examination*tool speimens ere transported in reri"erated!o<es either to the Miro!iolo"# Pa!orator#$ &ad'ah Mada (ni)ersit#$ %ault#o Mediine$ +o"#a,arta 9speimens rom *ard'ito$ *an"lah$ and Mataramhospitals;$ or to the ioarma Pa!orator#$ Jest 0a)a 9speimens romMuhammad Hussein$ Cipto Man"un,usumo$ and Hasan *adi,in hospitals;. /nthe la!orator#$ the sample as aliQuoted and stored at R7>NC. ota)irus asdeteted usin" an en#me immunoassa# 9Da,opatts Da,o /nternational; inaordane ith the manuaturerSs instrutions. All rota)irus=positi)e stoolspeimens ere sent to the &ad'ah Mada (ni)ersit# Pa!orator# or rota)irusstrain harateriation. %ort# randoml# seleted strains rom eahpartiipatin" hospital 924> in total; ere t#ped durin" the stud# periodEthical considerations his stud# as appro)ed !# the Fthial Committeeo esearh in Medial Health at %ault# o Mediine$ &ad'ah Mada(ni)ersit#$ and !# -AH 9*eattle$ Jashin"ton;. /normed onsent aso!tained rom parents or areta,ers o eli"i!le hildren !eore enrollment inthe stud#-re)ious *etione<t *etion

Results

Hospital-based surveillance%rom 0anuar# throu"h Deem!er 2>>6$ a totalo 287> hildren a"ed ?5 #ears ere hospitalied or aute diarrhea in the 6partiipatin" hospitals. @ these$ 23>7 hildren 98>; ere enrolled in thisstud#. *tool speimens ere tested or 224> 97; o all hildren enrolled. he remainin" 67 hildren either ere dishar"ed !eore a stool sample aso!tained or pro)ided an inadeQuate amount o stool speimen or testin". @the 224> stool samples tested$ 1345 96>; ere positi)e or rota)irus. heperenta"e o hildren hose samples tested positi)e or rota)irus ran"edrom 3 to 67 at the diIerent stud# sites 9 a!le 1;. @ the enrolled

hildren$ 2 died as a result o se)ere diarrhea 9!oth ere rota)irus ne"ati)e;and another 7 died o auses other than diarrhea he perenta"e o rota)irus=positi)e ases as hi"h in all a"e "roups !ut ashi"hest amon" hildren a"ed 6B11 months 964; and 12B23 months 967;.Je ound an une<petedl# hi"h pre)alene o rota)irus 932; amon" inantsa"ed ?3 months. Children a"ed ?2 #ears aounted or 1185 988; o the1345 inpatients ith rota)irus=positi)e diarrhea durin" the stud# period. hemedian a"e o enrolled hildren and o hildren ith rota)irus=positi)e

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diarrhea as 11 months. @)erall$ male indi)iduals ere more li,el# to !ehospitalied or diarrhea than ere emale indi)iduals 96> )s 4>;$ !ut thisse< diIerene as not statistiall# si"niLant !eteen rota)irus=positi)e androta)irus=ne"ati)e hildren. ota)irus=positi)e hildren ere more li,el# toe<periene deh#dration 9odds ratio @E$ 2.3 5 onLdene inter)al C/E$

1.7B2.; and )omitin" 9@$ 3.> 5 C/$ 2.4B3.6; and ere less li,el# to ha)e!lood# diarrhea 9@$ >.3 5 C/$ 1.7B4.6; than ere rota)irus=ne"ati)ehildren. he pre)alene o e)er or muus in the stool as not si"niLantl#diIerent !eteen rota)irus=positi)e and rota)irus=ne"ati)e patients. eorehospitaliation$ 61 o hildren ho tested positi)e or rota)irus hadreei)ed oral reh#dration salt$ 28 had reei)ed anti!iotis$ 17 hadreei)ed antiemetis$ and 14 had reei)ed antidiarrheal a"ents 9 a!le 2;ota)irus inetion ourred #ear=round at all sites$ ith a pea, durin" theolder months o 0une and 0ul#$ hen the rota)irus pre)alene rose to 7>B75$ ater hih the pre)alene steadil# dereased until Deem!er 933;9%i"ure 2;

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!igure 2

*easonalit# o rota)irus inetion amon" hildren in 6 hospitals in /ndonesia$2>>6

Outpatient surveillance hree o the partiipatin" hospitals also enrolledhildren ho presented ith diarrhea or outpatient are. @ 27$ 2$ and 12>stool speimens olleted rom outpatients in Hasan *adi,in Hospital$*ard'ito Hospital$ and Mataram Hospital$ respeti)el#$ 11 941;$ 3 91>;$ and5 94; tested positi)e or rota)irus 9 a!le 1;. *imilar to the Lndin"s amon"hospitalied patients$ the ma'orit# o outpatient rota)irus ases 986;ourred in hildren a"ed ?24 months$ and rota)irus pre)alene inreased in

the months o Ma# throu"h 0ul#. Amon" the outpatients$ the 73 rota)irus=positi)e hildren ere more li,el# to present ith )omitin" 971 )s 34 @$4.8 5 C/$ 2.5B.2; and deh#dration 96 )s 26 @$ 6.1 5 C/$ 3.2B11.8; and ere less li,el# to ha)e !lood in the stool 93 )s 16 @$ >.25 C/$ >.>3B>.6;$ ompared ith the 1>3 rota)irus=ne"ati)e hildren

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!igure 3

Distri!ution o & "enot#pes(A) and - "enot#pes (B) o rota)irus strains at 6sites in /ndonesia$ 2>>6

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!igure 4

ota)irus strain distri!ution in /ndonesia$ 2>>6

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Table 1

Fnrollment o -atients ith Diarrhea and esults o ota)irus estin" amon"Children A"ed ?5 +ears at 6 Hospitals in /ndonesia$ 2>>6

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Table 2

Charateristis and Clinial *#mptoms o Hospitalied Children A"ed ?5 +ears ith ota)irus Diarrhea$ /ndonesia$ 1 0anuar#B31 Deem!er 2>>6

GenotypingMoleular harateriation as perormed on 24> speimens

that ere positi)e or rota)irus !# en#me immunoassa#$ to determine & and- "enot#pes. & "enot#pes o rota)irus ere deteted or 1 983; o thesamples. he ma'orit# o strains had "enot#pes &1 and &$ hih aountedor 73 93>; and 6 92; o the 24> samples$ respeti)el#$ olloed !# &2$hih aounted or 34 speimens 914;. @ther "enot#pes inluded &39>.4; and &4 9>.4;. he remainin" samples ere mi<ed t#pes 9; 9%i"ure3 A;. @ the 24> samples$ 18 97; ere suessull# - "enot#ped. -4E and-8E anti"ens ere present in 31 916; and 33 917; o the 18 t#pedstrains$ respeti)el#$ !ut an une<petedl# hi"h pre)alene 91>5 56E o18; o "enot#pe -6E as deteted. Mi<ed inetions and unt#pea!leinetions aounted or and 21 o samples$ respeti)el# 9%i"ure 3B;.

 he median a"e o hildren ineted ith -6E "enot#pe strains as the sameas those ineted ith strains o other - t#pes 911 months;oth & and - "enot#pes ere esta!lished or 123 951; o the 24> rota)irus=positi)e samples. &1-6E and &-6E aounted or 34 and 21 osamples$ respeti)el#. @ther "enot#pes inluded &2-4E 917;$ &1-8E911;$ and &-8E 9;. he remainin" "enot#pes ere &1-4E$ &2-6E$&-4E$ and &3-4E$ hih aounted or 2$ 3$ 2$ and 1$ respeti)el#9%i"ure 4;-re)ious *etione<t *etion

Discussion

 his stud# demonstrates that rota)irus inetion is the most ommon auseo se)ere aute diarrhea amon" hildren a"ed ?5 #ears in /ndonesia.ota)irus as identiLed in 6> o the 224> hildren hospitalied ith autediarrhea and in 41 o the hildren ho presented ith diarrhea at theoutpatient linis. he ma'orit# 988; o all ases o rota)irus diseaseourred in hildren a"ed ?2 #ears. ota)irus=positi)e "astroenteritis asassoiated ith more )omitin" and deh#dration$ ompared ith rota)irus=ne"ati)e "astroenteritis. @ur stud# ound a hi"h pre)alene o -6E t#pe

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strainsOhih ere predominatel# the relati)el# unusual &1-6E and &-6EstrainsOand unt#pea!le strains. he urrentl# a)aila!le )aines do notontain & or -6E anti"ens$ so these results hi"hli"ht the importane oontinued strain monitorin" in /ndonesia and additional la!orator# eIorts tot#pe strains !eore and ater )aine introdution$ to measure )aine

eIeti)eness a"ainst all strains-re)ious studies onduted in /ndonesia in the late 17>s deteted rota)irusin 15 o patients ith mild diarrhea and up to 38 o hildren ith se)ereaute diarrhea. hese results are onsidera!l# loer than !oth our initialLndin"s rom 3 sites 957; and our urrent Lndin"s 3$ 5B7E. A reent stud#reported that the o)erall pre)alene o rota)irus amon" hildren a"ed ?5#ears ho see, are or diarrhea in /ndonesia as 45.5 11E$ !ut the resultso that stud# are difult to ompare ith those o our stud#$ !eause thea"e "roups ere a little diIerent$ and outpatient )isits ere inluded ithhospitaliations. easons or the inreased pre)alene o rota)irus diarrheain reent #ears inlude the use o more=sensiti)e dia"nosti tests anddereases in the num!er o !aterial and parasiti "astrointestinal inetions$as a result o impro)ements in sanitation and ater saet#$ hih ouldredue the reQuen# o all=ause diarrhea !ut inrease the proportion odisease aused !# rota)irusKer# e data ha)e !een olleted on hildren ho present ith diarrhea oroutpatient are in Asia. A ommunit#=!ased stud# in hailand ound that 12o hildren ith diarrhea at a lini tested positi)e or rota)irus$ hereas theperenta"e o hildren hospitalied ith aute diarrhea ho tested positi)eor rota)irus as 43 12E. he perenta"e ho tested positi)e or rota)irusin our stud# as hi"h$ ompared ith that in the hai stud# and also ithreported pre)alenes o 1>B2> amon" outpatients in the (nited *tatesand Chile 13$ 14E. @ur Lndin"s are nonetheless onsistent ith the "eneralLndin" that the pre)alene o rota)irus amon" hospitaliations or diarrhea ishi"her than that amon" episodes o milder diarrhea treated in linis@ur Lndin"s onLrm that hildren a"ed ?3 months are less li,el# to ha)erota)irus diarrhea$ hih is li,el# to !e partl# !ut not e<lusi)el# !eause otransplaental neutraliin" immuno"lo!ulin & anti!odies andimmuno"lo!ulin A in !reast mil,. Human !reast mil, also ontains se)eralomponents$ inludin" mil, muin$ that ha)e !een shon to inhi!it rota)irusrepliation and inetion !# !indin" to the )irus 15E. @ne stud# shoed thate<lusi)e !reast=eedin" pro)ides !etter protetion a"ainst se)ere rota)irus

inetion than partial or no !reast=eedin" 16E. %urthermore$ a lon"itudinalstud# in)ol)in" (* hildren shoed a redued ris, o diarrhea amon" thoseho ere mostl# !reast=ed durin" the Lrst 6 months o lie 17ECountries ith tropial limates usuall# sho little seasonal )ariation inrota)irus$ ompared ith those ith temperate limates 12$ 18E. Je oundthat rota)irus=positi)e diarrhea ourred #ear=round !ut that there as anapparent inrease in rota)irus pre)alene in the ool$ dr# season. his isonsistent ith our pre)ious stud# in 2>>1B2>>4 that shoed a lear

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seasonal trend o rota)irus inetion ourrin" in the dr# season 9authorsSunpu!lished data;. A stud# in M#anmar also reported that rota)irus inetionas hi"hest durin" the ool$ dr# season and dereased in the hot$ dr# andthe hot$ et seasons 1E he inreased reQuen# o )omitin" and deh#dration in rota)irus inetion

ma# pose hallen"es to the administration o oral reh#dration salt and ma#inrease reliane on intra)enous uid therap#$ thus leadin" to hi"hertreatment osts. Cost estimation rom one o our studies re)ealed that therota)irus=assoiated eonomi !urden rom a health are s#stem perspeti)eas (*T14.536 million per #ear 9(*T3.46 per !irth annuall#; 2>E. Asu!stantial proportion o hildren ith rota)irus diarrhea reei)ed anti!iotis$anti)omitin" a"ents$ and antidiarrheal a"ents !eore the# )isited thehospital. Hoe)er$ almost 4> o hildren ith diarrhea had not reei)edoral reh#dration salt$ hih is the primar# treatment or an# deh#dratin"diarrheal illness$ hih emphasies the need or eduation amon" parentsand primar# health are pro)iders a!out appropriate initial treatment or

ater# diarrhea@)erall$ -6E as the most ommon - t#pe$ aountin" or 56 o the strainst#ped. -6E strains ha)e !een reported to !e )er# ommon amon" neonatesin an"ladesh 21E the# ere also ound in 2 921; o 137 hildren o alla"es in /ndia 22E. /n 16B1$ -6E strains ere reported to !e the mostpredominant - t#pe$ in assoiation ith &1 and &3 t#pes$ in a sur)e# oirulatin" strains in Aria 23E he "lo!all# ommon "enot#pes &1-8E and &2-4E ere not representedstron"l# in this stud# and aounted or onl# 11 and 17 o all strains$respeti)el#. Also$ the "enot#pes &3 and &4 ere ound onl# in +o"#a,arta$at lo pre)alenes 9>.4 eah;. hese Lndin"s are in ontrast to those o a

stud# onduted in 2>>1B2>>4 that shoed that &1-8E represented 62.5o all strains in /ndonesia 9authorsS unpu!lished data;. he results also diIerrom those o an older stud# in +o"#a,arta that ound that the 4 "lo!all#ommon & t#pes 9&1$ &2$ &3$ and &4; ere predominant 24E. he Lndin" o a hi"h proportion o & in our stud# orresponds ith reent reports that &is an emer"in" serot#pe in /ndonesia 11E and orldide 23$ 25$ 26E. @interest$ "enot#pe & as ound to !e predominant in -alem!an" andMataram$ here rota)irus pre)alene as hi"hestA hi"h perenta"e o strains ere unt#pea!le 921;$ perhaps !eause o asli"ht mismath !eteen primers and strains. Additional la!orator# studiesill !e needed to assess hether these unt#pea!le strains represent &3 and

&4 "enot#pes or perhaps unusual "enot#pes

oth the mono)alent attenuated human rota)irus )aine and thepenta)alent human=!o)ine rota)irus reassortant )aine ha)e demonstrated"ood efa# a"ainst t#pes &1B&4 and &. Hoe)er$ ith the e<eption o&2-4E$ the & t#pes are reQuentl# in om!ination ith -8E$ hih is the K-4protein ontained in !oth )aines$ and this ill ele)ate )aine efa#a"ainst heterolo"ous & t#pes 27B2E. Althou"h trial data su""est some

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efa# o !oth )aines a"ainst strains omprisin" & and - t#pes notpresent in the )aines$ the de"ree o protetion aIorded a"ainstheterolo"ous strains$ suh as &-6E ound in this stud#$ remains unlear@)erall$ our results hi"hli"ht the hi"h !urden o rota)irus disease$ thehan"in" di)ersit# o rota)irus strains irulatin" in /ndonesia !# loation and

#ear$ and the urrentl# hi"h pre)alene o "lo!all# unusual strains. Althou"hthe o)erall disease !urden in Aria and Asia is ell reo"nied$ the JorldHealth @r"aniation is aitin" or the results o )aine linial trials inpoorer ountries o these re"ions !eore the# ill e<tend the urrentreommendations or the routine use o a)aila!le rota)irus )aines in theAmerias and Furope. *tudies ha)e shon that$ in Asia$ rota)irus )ainesare hi"hl# ost=eIeti)e and are pro'eted to ha)e a lar"e impat on the!urden o se)ere rota)irus "astroenteritis 3>E. Moreo)er$ as a &AK/ AllianeBeli"i!le ountr#$ /ndonesia should Quali# or a lar"e su!sid# or the )aineost or a period o 5 #ears o omplement this stud#$ researh on the eonomi !urden o rota)irus in

/ndonesia ould urther support poli# ma,ers in ma,in" a deision a!outthe introdution o rota)irus )aine$ !# helpin" to assess the relati)eaIorda!ilit# o the ne rota)irus )aines. %inall#$ raisin" ommunit#aareness a!out rota)irus inetion and rota)irus )aines ill !e importantin omplementin" primar# strate"ies or reduin" the disease !urden.eent Qualitati)e researh has shon a lo aareness o rota)irus diseaseamon" poli# ma,ers$ health are pratitioners$ and the ommunit# in/ndonesia 8E. his su""ests that$ in addition to epidemiolo"ial andla!orator# data$ eduational ampai"ns need to !e tar"eted at the medialand nonmedial ommunities$ to inrease aareness a!out the dan"er orota)irus inetion and to "arner !road support rom these "roups !eore

)aine introdution-re)ious *etione<t *etion

 Acknowledgments

Je than, Carl ir,ood$ uth ishop$ and &raeme arnes 9Murdohesearh /nstitute; o"er &lass 9%o"art# /nternational Center;$ or supportHera irati 9%ault# o Mediine$ &ad'ah Mada (ni)ersit#; and /. -. *u,anto9- io %arma;$ or the la!orator# or, A!dul Jaha! and Altha *et#aan9Communit# Health and utrition esearh Pa!orator#$ %ault# o Mediine$&ad'ah Mada (ni)ersit#;$ or data anal#sis dotors$ nurses$ andadministrati)e staI at all stud# sites$ or helpin" ith the stud# and Ftt#/ndriati 9Department o Anthropolo"#$ &ad'ah Mada (ni)ersit#;$ or heromments and su""estion. Je are "rateul to all the researh assistants inthe Child Health Department$ %ault# o Mediine$ &ad'ah Mada (ni)ersit# A.J. Frlin Mul#adi$ Fra A"ustin$ Muhammad a#u *ason",o$ Dara osmailina-a!ittei$ Diarum -uspasari$ Puia *im!olon$ etno -alupi$ Ki,a @,taria$ahman Fdi *antoso$ Fnd# Jid#a -utranto$ Diatrie Anind#a'athie$ ri udi

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Hartomo$ Ma#a /ndriati$ Fmm# Choirina$ and Har#anto$ or their )alua!leontri!utions to this stud#

-re)ious *etione<t *etion

Footnotes

• 6-otential onits o interest none reported

• 6%inanial support -AH and ioarma

• 6*upplement sponsorship his artile as pu!lished as part o asupplement entitled U&lo!al ota)irus *ur)eillane -reparin" or the/ntrodution o ota)irus Kaines$V hih as prepared as a pro'et o theota)irus Kaine -ro"ram$ a partnership !eteen -AH$ the Jorld Health@r"aniation$ and the (* Centers or Disease Control and -re)ention$ andas unded in ull or in part !# the &AK/ Alliane

• 6 he Lndin"s and onlusions in this artile are those o the authorsand do not neessaril# represent the )ies o the (* Centers or Disease

Control and -re)ention• 6-resented in part 6th Jor,shop o the Asian ota)irus *ur)eillane

etor,$ an",o,$ hailand$ Deem!er 2>>7 and Annual *ientiL Meetin"$&ad'ah Mada (ni)ersit#$ +o"#a,arta$ /ndonesia$ Marh 2>>8

• W 2>> !# the /netious Diseases *oiet# o Ameria

-re)ious *etion 

References

1. 6 

Jorld Health @r"aniation. Fstimated rota)irus deaths or hildren under 5 #earso a"e 2>>4$ 527 >>>. A)aila!leathttpXX.ho.intXimmuniationYmonitorin"X!urdenXrota)irusYestimatesXenXinde<.html. Aessed 11 Ma# 2>>8.

2. 6 1. -arashar (D$2. Hummelman F&$3. resee 0*$4. Miller MA$5. &lass /

. &lo!al illness and deaths aused !# rota)irus disease in hildren. Fmer" /netDis2>>3565=72.MedlineJe! o *iene&oo"le *holar

3. 6 1. resee 0*$2. Hummelman F$3. elson A*$4. &lass /

. ota)irus in Asia the )alue o sur)eillane or inormin" deisions a!out theintrodution o ne )aines. 0 /net Dis 2>>512 *uppl 1*1=5.CrosseMedlineJe! o *iene&oo"le *holar

7/21/2019 Burden of Severe Rotavirus Diarrhea in Indonesia

http://slidepdf.com/reader/full/burden-of-severe-rotavirus-diarrhea-in-indonesia 12/16

4. 6 1. elson FA*$2. am 0*$3. resee 0*$4. et al

. Fstimates o rota)irus disease !urden in Hon" on" hospital=!ased

sur)eillane. 0 /net Dis 2>>512 *uppl 1*71=.A!stratX %FF %ull e<t

5. 6 1. *oenarto +$2. *e!odo $3. idho $4. et al

. Aute diarrhea and rota)irus inetion in ne!orn !a!ies and hildren in +o"#a,arta$ /ndonesia$ rom 0une 178 to 0une 17. 0 Clin Miro!iol 18114123=.A!stratX %FF %ull e<t

6. 6 1. *utoto$2. Mohtar MA$3. ar#adi$4. Jasisto

. Mor!idit# and mortalit# stud# on diarrhoeal diseases in orth 0a,artaOan ur!anarea. *outheast Asian 0 rop Med -u!li Health 182134>5=11.Medline&oo"le *holar

7. 6 1. *iman'unta, CH$2. Hasi!uan MA$3. *ire"ar P@$4. oiman /

. Ftiolo"i mi,ro!iolo"is pen#a,it diare a,ut. ull -enelitian esehatan 183111=.

&oo"le *holar8. 6 1. *impson F$2. Jittet *$3. onilla 0$4. &amaina $5. Coole# P

. (se o ormati)e researh in de)elopin" a ,noled"e translation approah torota)irus )aine introdution in de)elopin" ountries. MC -u!liHealth 2>>77281.CrosseMedline&oo"le *holar

. 6 1. Jorld Health @r"aniation

. %ield test )ersion. &ene)a Jorld Health @r"aniation 2>>2. &eneri protoolsor 9i; hospital=!ased sur)eillane to estimate the !urden o rota)irus"astroenteritis in hildren and 9ii; a ommunit#=!ased sur)e# on utiliation ohealth are ser)ies or "astroenteritis in hildren.A)aila!le athttpXX.ho.intX)aines=doumentsXDos-D%>2X68.pd. Aessed 6

 0anuar# 2>>8.1>. 6 1. Jorld Health @r"aniation

7/21/2019 Burden of Severe Rotavirus Diarrhea in Indonesia

http://slidepdf.com/reader/full/burden-of-severe-rotavirus-diarrhea-in-indonesia 13/16

. &ene)a Jorld Health @r"aniation 2>>5. he treatment o diarrhoea a manualor ph#siians and other senior health or,ers.A)aila!le athttpXXhQli!do.ho.intXpu!liationsX2>>5X2415318>.pd. Aessed 4 0ul# 2>>8.

11. 6 1. -utnam *D$2. *ed#anin"sih F$

3. Pisti#anin"sih F$4. et al

. &roup A rota)irus=assoiated diarrhea in hildren see,in" treatment in/ndonesia. 0 Clin Kirol2>>74>28=4.CrosseMedlineJe! o *iene&oo"le *holar

12. 6 1. 0iraphon"sa C$2. reese C*$3. -on"suanna +$4. et al

. Fpidemiolo"# and !urden o rota)irus in hailand results o sentinelsur)eillane. 0 /net Dis 2>>512 *uppl 1*87=3.CrosseMedlineJe! o *iene&oo"le *holar

13. 6 1. Jiddoson M=A$2. Melter M/$3. Zhan" [$4. resee 0*$5. -arashar (D

. Cost=eIeti)eness and potential impat o rota)irus )aination in the (nited*tates.-ediatris 2>>711684=7.A!stratX %FF %ull e<t

14. 6 1. @S#an M$2. D\a 0$

3. Mamani $4. a)arrete M$5. Kalle!uono C

. /mpat o rota)irus inetions on outpatient lini )isits in Chile. -ediatr /net Dis 0 2>>72641=5.CrosseMedlineJe! o *iene&oo"le *holar

15. 6 1. +ol,en H$2. -eterson 0A$3. Kondereht *P$4. %outs F$5. Midthun  

. Human mil, muin inhi!its rota)irus repliation and pre)ents e<perimental"astroenteritis. 0 Clin /n)est 12>184=1.MedlineJe! o *iene&oo"le *holar

16. 6 1. Clemens 0$2. ao M$3. Ahmed %$4. et al

7/21/2019 Burden of Severe Rotavirus Diarrhea in Indonesia

http://slidepdf.com/reader/full/burden-of-severe-rotavirus-diarrhea-in-indonesia 14/16

. reast=eedin" and the ris, o lie=threatenin" rota)irus diarrhea pre)ention orpostponement. -ediatris13268>=5.A!stratX %FF %ull e<t

17. 6 1. *ariati -D$2. &rummer=*tran PM$

3. %ein *. A lon"itudinal anal#sis o inant mor!idit# and the e<tent o !reasteedin" in the(nited *tates. -ediatris17e5=e5.A!stratX %FF %ull e<t

18. 6 1. Doell *%

. *easonal )ariation in host susepti!ilit# and #les o ertain inetiousdiseases. Fmer" /net Dis 2>>1736=74.MedlineJe! o *iene&oo"le *holar

1. 6 1. Moe $2. Hummelman F&$3. @o JM$4. Pin $5. Hte

. Hospital=!ased sur)eillane or rota)irus diarrhea in hildren in +an"on$M#anmar. 0 /net Dis 2>>512*uppl 1*111=3.CrosseMedlineJe! o *iene&oo"le *holar

2>. 6 1. Jilopo *A$2. il"ore -$3. osen *$4. et al

. Kaine *upplement ota)irus in /ndonesia. Assessin" the osts o introduin"the rota)irus )aine into /ndonesiaSs national immuniation pro"ramme. in

press;.&oo"le *holar

21. 6 1. il"ore -F$2. (niom! P$3. &entsh 0$4. et al

. eonatal rota)irus inetion in an"ladesh strain harateriation and ris,ators or nosoomial inetion.-ediatr /net Dis 0 1615672=7.CrosseMedlineJe! o *iene&oo"le *holar

22. 6 1. ahl $2. a# -$3. *u!odh *$4. et al

. /nidene o se)ere rota)irus diarrhea in e Delhi$ /ndia$ and & and - t#pes othe inetin" rota)irus strains. 0 /net Dis2>>512 *uppl 1*114=.CrosseMedlineJe! o *iene&oo"le *holar

23. 6 1. *teele AD$2. /)anoI

7/21/2019 Burden of Severe Rotavirus Diarrhea in Indonesia

http://slidepdf.com/reader/full/burden-of-severe-rotavirus-diarrhea-in-indonesia 15/16

. ota)irus strains irulatin" in Aria durin" 16B1 emer"ene o & strainsand -6E strains. Kaine 2>>321361=7.CrosseMedlineJe! o *iene&oo"le *holar

24. 6 1. ishop %$2. (niom! PF$

3. *oenarto +$4. *uard'i H$5. istanto

. ota)irus serot#pes ausin" aute diarrhoea in hospitalied hildren in +o"#a,arta$ /ndonesia durin" 178B17. Arh Kirol 181>72>7=13.CrosseMedlineJe! o *iene&oo"le *holar

25. 6 1. 0ain K$2. Das M$3. han M$4. et al

. &reat di)ersit# o "roup A rota)irus strains and hi"h pre)alene o mi<edrota)irus inetions in /ndia. 0 Clin Miro!iol2>>133524=.A!stratX %FF %ull e<t

26. 6 1. *antos $2. Kolotao FM$3. *oares CC$4. et al

. -redominane o rota)irus "enot#pe & durin" the 1$ 2>>>$ and 2>>2seasons amon" hospitalied hildren in the it# o *al)ador$ ahia$ railimpliations or uture )aine strate"ies. 0 Clin Miro!iol 2>>5434>64=.A!stratX %FF %ull e<t

27. 6 1. ui=-alaios &M$

2. -ere=*hael /$3. KelaQue %$4. et al

. *aet# and efa# o an attenuated )aine a"ainst se)ere rota)irus"astroenteritis. Fn"l 0 Med2>>635411=22.CrosseMedlineJe! o *iene&oo"le *holar

28. 6 1. Kesi,ari $2. Matson D@$3. Denneh# -$4. et al

. *aet# and efa# o a penta)alent human=!o)ine 9JC3; reassortant rota)irus)aine. Fn"l 0 Med 2>>635423=33.CrosseMedlineJe! o *iene&oo"le *holar

2. 6 1. Kesi,ari $2. ar)onen A$3. -r#mula $4. et al

. Ffa# o human rota)irus "astroenteritis durin" the Lrst 2 #ears o lie inFuropean inants randomised$ dou!le=!lind stud#. Panet 2>>737>1757=63.

7/21/2019 Burden of Severe Rotavirus Diarrhea in Indonesia

http://slidepdf.com/reader/full/burden-of-severe-rotavirus-diarrhea-in-indonesia 16/16

CrosseMedlineJe! o *iene&oo"le *holar

3>. 6 1. -odeils P0$2. Antil P$3. Hummelman F$4. resee 0$

5. -arashar (D. -ro'eted ost=eIeti)eness o rota)irus )aination or hildren in Asia. 0 /netDis 2>>512*uppl 1*133=45.CrosseMedlineJe! o *iene&oo"le *holar