Long-term transmission dynamics may differ from those in the first few years after licensure based on the steady-state levels of protection among children overall, due to gradually increasing vaccine coverage among young children, aging of the initial cohort of vaccinated individuals and complex dynamics of indirect benefits ( 7). The long-term impacts of rotavirus vaccination, particularly in LMICs, are unclear and will require further evaluation. While some early-introducing countries integrated rotavirus vaccine into their national immunization programs as early as 2006, many African nations did not implement rotavirus vaccination until 2012 or later ( 5), and most low- and middle-income countries (LMICs) in Asia have not yet introduced rotavirus vaccines. ![]() While vaccine efficacy is high in high-income countries (84 to 90%), there is a gradient of lower protection in middle- (~75%) and lower-income settings (~50%) where burden is highest ( 6). ![]() All four vaccines have received WHO prequalification ( 4), and Rotarix is currently the product most used in low- and middle-income countries that have introduced rotavirus vaccination into their national immunization programs ( 5). In recent years, two additional three-dose vaccines have become available, Rotavac and ROTASIIL, which are also live oral vaccines with similar safety and efficacy profiles. In 2009, two live, attenuated oral rotavirus vaccines were recommended for global use: Rotarix, a monovalent vaccine administered in a two-dose series, and RotaTeq, a pentavalent vaccine with a three-dose series. ![]() Diarrhea is a leading cause of under-five mortality worldwide ( 1), and rotavirus is a predominant etiology of diarrhea mortality ( 2), estimated to cause 128,500 deaths worldwide as of 2016 ( 3).
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