Vaccine xxx (2018) xxx–xxx

Contents lists available at ScienceDirect

Vaccine
journal homepage: www.elsevier.com/locate/vaccine

Diarrhea among hospitalized children under five: A call for inclusion of

rotavirus vaccine to the national immunization program in Indonesia
Nenny Sri Mulyani a,b,⇑, Dwi Prasetyo c, I. Putu Gede Karyana d, Wayan Sukardi e,
Wahyu Damayanti a,b, Dian Anggraini f, Retno Palupi-Baroto a,b, Hera Nirwati g,b,
Abdul Wahab h,b, Asal Wahyuni Erlin Mulyadi i,b, Tomoka Nakamura j, Yati Soenarto a,b
a
Department of Child Health, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada/Dr. Sardjito Hospital, Yogyakarta, Indonesia
b
Pediatric Research Office, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada/Dr. Sardjito Hospital, Yogyakarta, Indonesia
c
Department of Child Health, Faculty of Medicine, Universitas Padjajaran/Dr. Hasan Sadikin Hospital, Bandung, Indonesia
d
Department of Child Health, Faculty of Medicine, Universitas Udayana/Sanglah Hospital, Denpasar, Indonesia
e
Department of Child Health, Faculty of Medicine, Universitas Mataram/Nusa Tenggara Barat Provincial Hospital, Mataram, Indonesia
f
Department of Child Health, Wates District Hospital, Kulonprogo, Yogyakarta, Indonesia
g
Department of Microbiology, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia
h
Department of Biostatistics, Epidemiology, and Population Health, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia
i
Department of Public Administration, Faculty of Social and Political Sciences, Universitas Sebelas Maret, Surakarta, Indonesia
j
Expanded Programme on Immunization, Department of Immunization, Vaccines, and Biologicals, World Health Organization (WHO), Geneva, Switzerland

a r t i c l e i n f o a b s t r a c t

Article history: Context: Rotavirus diarrhea is a common disease worldwide which mostly affects children under five
Available online xxxx years old. Rotavirus infection causes severe diarrhea and leads to substantial health care costs. In
Indonesia the rotavirus vaccine has been available since 2011, however it has not been included into
Keywords: the National Immunization Program. This study aims to describe the proportion of rotavirus in children
Diarrhea under 5 in Indonesia, the clinical characteristics of rotavirus infections, and the rotavirus strains circulat-
Children under five ing in the country during 2010–2015.
Rotavirus vaccine
Methods: Children under five years of age with acute watery diarrhea were prospectively identified and
Indonesia
enrolled through the active diarrhea surveillance system in 5 sites in four provinces in Indonesia during
2010–2015. The rotavirus specimens were tested using Enzyme Immunoassay. Bivariate logistic regres-
sion tests were performed to compare rotavirus positive and negative results with respect to the collected
demographic and clinical variables.
Results: From January 2010 to December 2015, the average annual rotavirus prevalence among children
hospitalized with acute watery diarrhea in four provinces in Indonesia was 47.5%. Rotavirus diarrhea
occurred mostly in children under 2 years of age. Of all age groups, children aged 6–11 and 12–23 months
had the highest prevalence of rotavirus diarrhea in all years (54.2% and 50.6%, respectively). This study
found that the most prevalent of G and P genotypes were G1P8 in 2010 (63.2%), 2011 (64.1%) and
2012 (74.6%) and G3P8 in 2013 (49.7%), 2014 (82.5%) and 2015 (84.4%)
Conclusions: This study demonstrates that rotavirus is a major cause of diarrhea in hospitalized children
in Indonesia. These findings highlight the need for inclusion of the rotavirus vaccine to the National
Immunization Program in Indonesia.
Ó 2018 Elsevier Ltd. All rights reserved.

1. Introduction
Diarrheal disease is the second major cause of death after pneu-
monia in children under the age of five years (U5) globally [1] The
⇑ Corresponding author at: Department of Child Health, Faculty of Medicine,
Public Health and Nursing, Universitas Gadjah Mada/Dr. Sardjito Hospital,
Yogyakarta, Indonesia.
E-mail address: rotavirus_yogyakarta@yahoo.com (N.S. Mulyani).
Indonesian National Basic Health Research 2013 [2] revealed that
the national prevalence of diarrhea in Indonesia was 7.0% for all
age groups, mostly caused by infection, with peak prevalence in
1–4 years of age (12.2%). Rotavirus is the common cause of severe
diarrhea and leads to substantial death [3,4]. The estimated pro-
portion of rotavirus-related deaths worldwide in children U5 was
37.3% of total diarrhea mortality (n = 214,806) in 2013. In South-
east Asia, approximately 50.7% (n = 10,765) of total diarrhea mor-
tality was caused by rotavirus during 2000–2013 [5]. This was

https://doi.org/10.1016/j.vaccine.2018.05.031
0264-410X/Ó 2018 Elsevier Ltd. All rights reserved.

Please cite this article in press as: Mulyani NS et al. Diarrhea among hospitalized children under five: A call for inclusion of rotavirus vaccine to the national
immunization program in Indonesia. Vaccine (2018), https://doi.org/10.1016/j.vaccine.2018.05.031
2 N.S. Mulyani et al. / Vaccine xxx (2018) xxx–xxx
similar to the proportion of rotavirus-related death reported in
Indonesia where 50.2% of total diarrhea deaths (n = 3771) was
caused by rotavirus during 2000–2013 [6]. Our previous study
showed that in 6 teaching (province) hospitals in Indonesia, rota-
virus infection was identified in 60% (n = 1345) of children hospi-
talized for acute diarrhea from January to December 2006 [7].
Rotavirus vaccine (RVV) has been demonstrated to have high
efficacy against severe rotavirus gastroenteritis in middle- and
high-income countries [8]. RVV was also found to be highly cost-
effective for Indonesia, with the assumption that a cost of US$ 14
per dose of rotavirus vaccine, hence the incremental cost-
effectiveness ratio would be equal to US$ 120.46 per disability
adjusted life years averted [9]. In Indonesia RVV has been commer-
cially available since 2011 and has been embedded into the
Indonesia Pediatric Association’s Recommended Immunization
Schedule for Children and Adolescents (aged 0–18 years old) [10],
however it has not yet been included in the Indonesia’s National
Immunization Program (NIP).
This article aims to describe the proportion of rotavirus in chil-
dren U5 in Indonesia, the clinical characteristics of rotavirus infec-
tions, and the rotavirus strains circulating in the country during
2010–2015.
2. Methods
Children U5 with acute watery diarrhea were prospectively
identified and enrolled through the active diarrhea surveillance
system as part of the WHO Global Rotavirus Surveillance Network.
Surveillance was conducted in 5 sites in 4 provinces in Indonesia
during 2010–2015 in accordance to the WHO Guidelines [11].
The participating hospitals that served as sentinel sites were Hasan
Sadikin Hospital (Bandung, West Java), Sardjito Hospital (Yogya-
karta), Sanglah Hospital (Bali), Mataram Hospital (Mataram, West
Nusa Tenggara) and Wates Hospital (Yogyakarta, participated from
2012). The surveillance system enrolled children U5 who were
admitted to these sentinel hospitals due to acute watery diarrhea.
Acute watery diarrhea was defined as looser-than-normal stool
with a frequency of more than or equal to three times a day and
a total duration of less than or equal to 14 days.
All eligible subjects were recruited by trained health workers
(doctors or nurses) and the parents/guardians were interviewed
after informed consent was obtained. Surveillance was conducted
daily at all the participating sites. Data entered on the case report-
ing forms (CRF) were derived from patients’ medical records. Sev-
ere dehydration is classified by two or more of the following signs:
lethargy/unconsciousness, sunken eyes, unable to drink/drinks
poorly, and/or skin goes back very slowly when pinched (2 s).
Some dehydration is defined when two or more of the following
signs are found: restlessness, irritability, sunken eyes, drinks
eagerly, thirsty, and/or skin goes back slowly when pinched [12]
(Table 1).
Stool samples were collected during the first 48 h of admission
based on WHO protocol and stored at 4–8 °C before being trans-
ported to the Department of Microbiology, Faculty of Medicine,
Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta.
The specimens were then aliquoted into several tubes and stored
at 20 °C. All stool samples were examined for the presence of
group A rotavirus by enzyme immunoassay (EIA), using the IDEIATM
Rotavirus (DakoCytomation) kit according to the instructions pro-
vided by the manufacturer. Rotavirus RNA was extracted from
rotavirus positive fecal specimens with Trizol (Invitrogen) or
QIAamp RNA stool minikit (Qiagen) according to the manufac-
turer’s instructions. From 2014, the WHO Global Rotavirus Surveil-
lance Network recommended to have 50 genotyped samples per
site to characterize the genotype distribution in each region. Thus,
Please cite this article in press as: Mulyani NS et al. Diarrhea among hospitalized children under five: A call for inclusion of rotavirus vaccine to the national
immunization program in Indonesia. Vaccine (2018), https://doi.org/10.1016/j.vaccine.2018.05.031
Table 1
Classification of the severity of dehydration in children with diarrhea.
Classification Sign or symptoms
Severe Two or more of the following signs:
dehydration  Lethargy/unconsciousness
 Sunken eyes
 Unable to drinks or drinks poorly
 Skin pinch goes back very slowly (2 s)
Some dehydration Two or more of the following signs:
 Restlessness, Irritability
 Sunken eyes
 Drinks eagerly, thirsty
 Skin pinch goes back slowly
No dehydration Not enough signs to classify as some or severe
dehydration
WHO, 2006 [12].
stratified random sampling was used to choose the samples to be
genotyped from each of the sentinel sites except for Yogyakarta
due to having <40 rotavirus positive fecal specimens. Rotavirus
RNAs were analyzed to determine both the VP7 (G-type) genotypes
using reverse transcription polymerase chain reaction (RT-PCR)
[13,14].
Data entry was done using EpiData 3.1 software, and STATA ver-
sion 13 was used for data analysis. Descriptive analysis was per-
formed to describe the proportion (percentage) of each category
from the selected variables. Bivariate logistic regression was per-
formed to compare positive and negative rotavirus results with
respect to the collected demographic and clinical variables with a
95% confidence interval (CI) and p value was considered statisti-
cally significant if p < 0.05. Data quality control was conducted
during and after data entry.
3. Results
From January 2010 to December 2015, a total of 4986 eligible
subjects who were children U5 were admitted with a diagnosis
of acute watery diarrhea at the participating hospitals. Of these,
4311 (86.5%) children were enrolled and 4013 (93.1%) fecal speci-
mens were tested for rotavirus. Children with bloody and persis-
tent diarrhea were excluded. This surveillance detected rotavirus
positivity at an annual average of 1950 (48.7%) subjects from Jan-
uary 2010 to December 2015, but it showed year-by-year fluctua-
tion, with the highest ranging from 509 (53.7%) children in 2010 to
the lowest at 208 (38.7%) children in 2014 (Table 2).
Among children that tested positive for rotavirus, the highest
proportion of positive cases was among the 6–11 and 12–23
months age groups (54.2% and 50.6%, respectively), while the low-
est proportion of positive cases was among the 0–5 months old
(38.4%). Rotavirus diarrhea occurred mostly in children under 2
years of age (U2). The odds of being positive for rotavirus in chil-
dren aged 6–11 months was 2 times that of those aged 0–5 months
(p-value < 0.001). Children who were tested positive with rotavirus
were more likely to experience some dehydration and vomiting
compared to rotavirus negative children (p-value < 0.001). The pro-
portion of children with rotavirus positive with some dehydration
was 53.5% while the proportion of children with rotavirus positive
with severe dehydration was 43.7%. The rotavirus positive group
was more likely to receive intravenous rehydration (p-value < 0.0
01) treatment than the rotavirus negative group (Table 3).
For the rotavirus strain distribution, more details are shown in
Table 4. In 2010, 2011 and 2012, G1P[8] was the most prevalent
genotype circulating in Indonesia which accounted for 63.2%;
64.1% and 74.6%, respectively. In 2013, G3P[8] became the most
predominant strain that accounted for 49.7%. The proportion of
G3P[8] increased in 2014 and 2015 which accounted for 82.5%
 N.S. Mulyani et al. / Vaccine xxx (2018) xxx–xxx 3

Table 2
Enrollment of children <5 years of age with diarrhea and results of rotavirus testing in Indonesia period 2010–2015.

Year Number of children Number (%) of children Number (%) with stool Number (%) with rotavirus
eligible enrolled specimen collected and positive stool*
tested
Number % Number % Number %
2010 1372 983 (71.6) 948 (96.4) 509 (53.7)
2011 723 661 (91.4) 620 (93.7) 330 (53.3)
2012 594 556 (93.6) 520 (93.5) 235 (45.1)
2013 637 592 (92.9) 562 (94.9) 234 (41.7)
2014 677 632 (93.3) 537 (84.9) 208 (38.7)
2015 983 887 (90.2) 826 (93.1) 434 (52.5)
2010–2015 4986 4311 (86.5) 4013 (93.1) 1950 (48.7)
*
47.5% for annual average of rotavirus positive for January 2010-Desember 2015, which is an analysis limited to full calendar years.

Table 3
Demographic and clinical characteristic of rotavirus diarrhea in children <5 years old in Indonesia period 2010–2015.

Characteristics Rotavirus positive Rotavirus negative p-value OR (95%CI)

n = 1950 (%) n = 2063 (%)
Sex
Male 1222 (49.0%) 1273 (51.0%) 0.531 1.04 (0.92–1.18)
Female 728 (48.0%) 790 (52.0%) Ref
Age in months
0–5 months 267 (38.4%) 429 (61.6%) 0.001* Ref
6–11 months 687 (54.2%) 581 (45.8%) 1.90 (1.57–2.29)
12–23 months 664 (50.6%) 649 (49.4%) 1.64 (1.36–1.98)
24–59 months 332 (45.1%) 404 (54.9%) 1.32 (1.07–1.63)
Clinical findings
Dehydration
Severe 111 (43.7%) 143 (56.3%) 1.51 (1.14–2.01)
Some 1537 (53.5%) 1337 (46.5%) 2.24 (1.91–2.62)
*
No 297 (33.9%) 578 (66.1%) 0.001 Ref
Vomiting
Yes 1583 (55.7%) 1257 (44.3%) 0.001* 2.76 (2.39–3.19)
No 367 (31.3%) 805 (68.7%) Ref
Fever
Yes 1256 (49.0%) 1305 (51.0%) 0.435 1.05 (0.93–1.20)
No 693 (47.8%) 758 (52.2%) Ref
Treatment
Oral rehydration (before hospitalization)
Yes 726 (53.3%) 637 (46.7%) 0.003* 1.24 (1.08–1.43)
No 847 (47.9%) 921 (52.1%) Ref
Intravenous rehydration
Yes 1744 (51.0%) 1675 (49.0%) 0.001* 1.96 (1.64–2.35)
No 206 (34.7%) 388 (65.3%) Ref
*
Significance at a 0.01; OR (Odds Ratio); 95% CI (95% confidence interval).

and 84.4%, respectively. In general, G1, G2 and G3 in conjunction
with P[4], P[6] and P[8] were the strains commonly circulating in
Indonesia.
In terms of seasonality, Fig. 1 shows that rotavirus infection was
present throughout the year and does not demonstrate clear
annual seasonality. It shows that the highest proportion of rota-
virus diarrhea occurred in January and April 2010; April and June
2011; April and May 2012; March and December 2013; June and
September 2014 and June and September 2015. Out of the 4311
children enrolled in this study from 2010 to 2015, the total number
of deaths was 45 with severe dehydration (35.5%), some dehydra-
tion (29.0%), and no dehydration (35.5%) during hospitalization.
4. Discussion
The active diarrhea surveillance system of Indonesia demon-
strated that rotavirus is a major cause of diarrhea in hospitalized
children nationally. This is similar to the study findings in India
in 2016 which stated that up to 50% of hospitalized children U5
are due to rotavirus diarrhea [15]. During the 6 years period when
surveillance was conducted in 4 provinces in Indonesia, the annual
proportion of rotavirus positivity among children being admitted
for acute watery diarrhea was 47.5%. This proportion was higher
than the mean of global rotavirus detection which was 36% [16],
and 37.5% in Asia [17]. On the other hand, it was similar to the
median rotavirus detection of 45% which was reported in South-
East Asia and the Western Pacific [18].
These surveillance findings identified that rotavirus diarrhea
occurred mostly in children U2, which is similar to the findings
described previously in several studies, including one in Indonesia
in 2006 where 88% of 1345 children tested positive for rotavirus
were U2 [7]. Additionally, 94% of global rotavirus deaths during
2011–2012 was among children U2 [16]. The lowest rotavirus
detection rate was in the older age group, which is similar to what
was found in India in 2014 (24% of 4711 children in the 24–59
months age of group) [19]. Innate and adaptive immune systems
start to develop after the infancy period and become more mature

Please cite this article in press as: Mulyani NS et al. Diarrhea among hospitalized children under five: A call for inclusion of rotavirus vaccine to the national
immunization program in Indonesia. Vaccine (2018), https://doi.org/10.1016/j.vaccine.2018.05.031
4 N.S. Mulyani et al. / Vaccine xxx (2018) xxx–xxx

Table 4
Rotavirus strain distribution in Indonesia period 2010–2015.

Genotype 2010 2011 2012 2013 2014 2015

n % n % n % n % n % n %
G untype P[untype] – – 2 1.1 – – 1 1.6
G untype P[4] – – – – – –
G untype P[4,6] – – – – – –
G untype P[6] – – 1 0.5 1 0.5 – –
G untype P[8] 3 1.8 – 16 8.6 5 2.6 – 3 4.7
G1P[untype] – 1 0.7 3 1.6 – – –
G1P[4] 6 3.5 16 10.5 – 1 0.5 – –
G1P[4,6] 1 0.6 – – – – –
G1P[4,8] 5 2.9 1 0.7 – – – –
G1P[6] 19 11.1 8 5.2 – – – –
G1P[6,8] 6 3.5 2 1.3 1 0.5 – – –
G1P[6,10] – – – – – –
G1P[8] 108 63.2 98 64.1 138 74.6 54 28.6 2 3.5 –
G1P[10] – – – – – –
G1,2P[4] 1 0.6 3 2.0 – – – –
G1,2P[4,6] – – – – – –
G1,2P[4,8] 1 0.6 – – – – –
G1,2P[6] 2 1.2 – 1 0.5 – – –
G1,3P[untype] – – – 1 0.5 – –
G1,3P[4] – – – – – –
G1,3P[4,6] – – – – – –
G1,3P[8] – – 2 1.1 1 0.5 – –
G1,12P[8] – – – 1 0.5 – –
G2P[untype] – – – – – – –
G2P[4] 13 7.6 17 11.1 1 0.5 3 1.6 1 1.8 –
G2P[4,6] – – – – – –
G2P[4,8] 2 1.2 1 0.7 – – – –
G2P[4,10] – – – – – –
G2P[6] – 5 3.3 7 3.8 6 3.2 7 12.3 4 6.3
G2P[6,8] – 1 0.7 – – – –
G2P[8] 4 2.3 – 3 1.6 3 1.6 – –
G2,3P[8] – – – 1 0.5 – –
G3P[untype] – – – 3 1.6 – –
G3P[4] – – 1 0.5 – – –
G3P[4.6] – – – – – –
G3P[6] – – 1 0.5 4 2.1 – 1 1.6
G3P[6,8] – – 1 0.5 – – –
G3P[8] – – 6 3.2 94 49.7 47 82.5 54 84.4
G3P[9] – – 1 0.5 – – –
G3,12P[untype] – – – 1 0.5 – –
G3,12P[8] – – – 2 1.1 – –
G9P[6] – – – – – –
G9P[8] – – – – – 1 1.6
G12P[8] – – – 8 4.2 – –
TOTAL 171 153 185 189 57 64

Seasonality of Rotavirus Diarrhea among Hospitalization Children <5 years of Age in Indonesia period 2010-2015
100 90.0
Seasonality of Rotavirus Diarrhea
90 80.0
Among Hospitalized Children <5 Years of Age
Number of specimens tested

80 70.0
70
60.0
60
50.0
50
40.0
40
30.0
30

20 20.0

10 10.0

0 0.0
Nov-15
Mar-10
May-10
Jul-10
Sep-10
Nov-10

Nov-11
May-11
Jul-11
Sep-11

May-12
Jul-12
Sep-12
Nov-12

Nov-13

Nov-14
Jan-10

Jan-11
Mar-11

Jan-12
Mar-12

Mar-13
May-13
Jul-13
Sep-13

May-15
Jul-15
Sep-15
Jan-13

Mar-14
May-14
Jul-14
Sep-14
Jan-14

Jan-15
Mar-15

Rotavirus Posive Rotavirus Negave % Rotavirus Posive

Fig. 1. Seasonality of rotavirus diarrhea among hospitalization children <5 years of age in Indonesia period 2010–2015.

Please cite this article in press as: Mulyani NS et al. Diarrhea among hospitalized children under five: A call for inclusion of rotavirus vaccine to the national
immunization program in Indonesia. Vaccine (2018), https://doi.org/10.1016/j.vaccine.2018.05.031
 N.S. Mulyani et al. / Vaccine xxx (2018) xxx–xxx
in older children [20]. Children who acquire natural infections of
rotavirus develop immunity to subsequent rotavirus infections,
thus decreasing the severity [21]. Hence, this strengthens the evi-
dence to encourage complete vaccinations administered to chil-
dren U2 [22], since a study in India found that RVV can prevent
deaths caused by rotavirus diarrhea in children U5 over the next
decade [15]. In fact, children under three months had a low rota-
virus positivity (4.5%), possibly due to the transfer of maternal
rotavirus-specific antibodies to the newborns via the placenta
and breast milk as found in another study in Indonesia [23].
Human breast milk contains abundant protective factors against
the rotavirus antigen such as immunoglobulin A, mucin, trypsin
inhibitors [24], lactadherin [25] and lactoferrin [26] which have
mainly been found in infants younger than 6 months as a result
of exclusive breastfeeding.
The rotavirus positive group was associated with some dehy-
dration and vomiting which indicate the severity of rotavirus diar-
rhea, similar to findings of other studies [7,19]. Rotavirus-induced
diarrhea and vomiting often leads to severe dehydration as vomit-
ing prevents oral rehydration treatment (ORT) from being admin-
istered sufficiently. ORT is one of the five steps in Indonesia’s
national recommendations to treat diarrhea (in addition to exclu-
sive breastfeeding, zinc, antibiotic for bacterial cause and educa-
tion) [27]. In our study, the number of cases that received oral
rehydration (before hospitalization) as well as intravenous rehy-
dration is higher in the rotavirus positive group than the negative
group.
Rotavirus diarrhea cases in Indonesia tend to be detected
throughout the entire year, as described previously in 2009 [7]
and documented by other findings in South-East Asia [28,29]. Sim-
ilar to our findings, rotavirus was found to have a distinct seasonal
peak in countries with temperate climates but, it was found to be
year-round in the tropics [30]. These surveillance results demon-
strated a changing trend of the most prevalent genotype each year,
from G1P[8] in 2010–2012 to G3P[8] in 2013–2015. Most of the
strains circulating in Indonesia were similar to the strains circulat-
ing in the world (G1, G2, and G3) even though the proportions fluc-
tuated. Genotypes G1, G2, and G3 in conjunction with P[4], P[6],
and P[8], were found circulating in Indonesia. The WHO Global
Rotavirus Surveillance Network from 2008 to 2012 described that
the most frequently observed rotavirus genotypes during 2009–
2012 included G1P[8], G2P[4], G3P[8], G4P[8], and G9P[8] [31].
These results emphasized the necessity for continuous rotavirus
monitoring to identify the circulating rotavirus strains before and
after vaccine introduction. This approach will continue to provide
information on how RVV can impact genotype distribution and
the possible emergence of less common rotavirus strains circulat-
ing in certain geographical areas. One limitation involves the fact
that the vaccination status of the children enrolled in surveillance
was only assessed in 2014 and 2015. In addition, other data
sources on vaccination of RVV are still not readily available in
Indonesia due to the fact that RVV is not yet recommended as part
of the National Immunization Program. Therefore, further assess-
ment on the approximate coverage of RVV among children in
Indonesia may be beneficial in the future when comparing the dis-
ease burden pre- vs. post-vaccine introduction.
5. Conclusion
Rotavirus is a significant cause of severe diarrhea among very
young children in Indonesia. Since improved sanitation conditions
and personal hygiene are inadequate to control rotavirus infection,
vaccination is the only expected solution to further reduce this
health risk. The consistently high burden of diarrhea in children
highlights the urgency for Indonesian policy makers to implement
RVV in the National Immunization Program. In addition, the con-
Please cite this article in press as: Mulyani NS et al. Diarrhea among hospitalized children under five: A call for inclusion of rotavirus vaccine to the national
immunization program in Indonesia. Vaccine (2018), https://doi.org/10.1016/j.vaccine.2018.05.031
5
tinuous surveillance of rotavirus and other common enteropatho-
gens is necessary to document the ongoing burden and to
evaluate the impact of RVV when nationally introduced.
Conflict of interest
All of the authors declare they have no conflict of interest rele-
vant to this article.
Acknowledgements
We acknowledge the contribution of the research assistants: Saras-
titi Alifaningdyah, William Sumoro, Dessy Herawati, Rizki Anin-
dita, Agus Gunadi, and Gandhes Anggriska Widriavi.
Funding
This work was supported by the World Health Organization
(WHO).
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Please cite this article in press as: Mulyani NS et al. Diarrhea among hospitalized children under five: A call for inclusion of rotavirus vaccine to the national
immunization program in Indonesia. Vaccine (2018), https://doi.org/10.1016/j.vaccine.2018.05.031