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Rotavirus is responsible for more than half a million deaths among infants and young children worldwide each year; many of these deaths could be prevented by widespread use of an effective rotavirus vaccine. The diversity of rotavirus strains in many developing countries, where most rotavirus deaths occur, could represent a significant challenge to the efficacy of current vaccines. In anticipation of rotavirus vaccine introduction, we examined studies published over a 10-year period (1997–2006) from countries in Africa that examined the distribution of VP7 (G) and VP4 (P) rotavirus strain types in symptomatic children and in neonates, together with studies that undertook a more detailed characterization of unusual rotavirus strains. Compared with recently published global reviews of rotavirus strain types and a previous review of the African literature published before 1997, the current data indicate a substantially increased diversity of rotavirus strains across the continent. Notable findings included a reduction in the proportion of globally common serotypes; a high proportion of unusual P/G combinations, suggesting viral reassortment; evidence for zoonotic rotavirus transmission; the emergence and spread across Africa of serotype G9; and a high prevalence of the P[6] VP4 genotype. These data imply that rotavirus vaccines will need to confer protection against a wide variety of strain types in Africa and emphasize the importance of continued strain surveillance before and after the introduction of routine rotavirus vaccination.

Background In South Africa, there are limited data on the burden of diarrhoea at a community level, specifically in older children and adults. This community survey estimated rates of and factors associated with diarrhoea across all ages and determined the proportion of cases presenting to healthcare facilities. Methods Households were enrolled from an existing urban health and demographic surveillance site. A household representative was interviewed to determine associated factors and occurrence of diarrhoea in the household, for all household members, in the past 2 weeks (including symptoms and health seeking behaviour). Diarrhoeal rate of any severity was calculated for < 5 years, 5–15 years and > 15 years age groups. Factors associated with diarrhoea and health seeking behaviour were investigated using binomial logistic regression. Results Diarrhoeal rate among respondents (2.5 episodes/person-year (95% CI, 1.8–3.5)) was significantly higher than for other household members (1.0 episodes/person-year (95% CI, 0.8–1.4); IRR = 2.4 (95% CI, 1.5–3.7) p  < 0.001). Diarrhoeal rates were similar between age groups, however younger children (< 5 years) were more likely to present to healthcare facilities than adults (OR = 5.9 (95% CI, 1.1–31.4), p  = 0.039). Oral rehydration solution was used in 44.8% of cases. Having a child between 5 and 15 years in the household was associated with diarrhoea (OR = 2.3 (95% CI, 1.3–3.9), p  = 0.003) and, while 26.4% of cases sought healthcare, only 4.6% were hospitalised and only 3.4% of cases had a stool specimen collected. While the majority of cases were mild, 13.8% of cases felt they required healthcare but were unable to access it. Conclusion Diarrhoeal rate was high across all age groups in this community; however, older children and adults were less likely to present to healthcare, and are therefore underrepresented through facility-based clinical surveillance. Current diarrhoeal surveillance represents a fraction of the overall cases occurring in the community.

Background Stool samples submitted for diagnostic testing represent a proportion of diarrhoeal cases seeking healthcare, and an even smaller proportion of diarrhoeal cases in the community. Despite this, surveillance relies heavily on these laboratory results. This study described diarrhoeal diagnostic practices and aetiological agents of diarrhoea in patients admitted to three South African public hospitals in order to understand biases in surveillance data, and inform guidelines, diagnostic and laboratory practices to improve clinical management. Methods A doctors’ survey was conducted to determine sample submission, diarrhoeal treatment and barriers to submitting samples for testing. Results for all samples submitted for routine diagnostics were obtained from the NHLS Central Data Warehouse. An enhanced surveillance study enrolled patients with acute diarrhoea at the same hospitals over the same period. Differences between routine culture results and molecular testing from the surveillance study were described. Results Stool samples were seldom submitted for diagnostic testing (median of 10% of admitted cases). Current diagnostic guidelines were not useful, hence most doctors (75.1%) relied on their own clinical judgement or judgement of a senior clinician. Although most doctors (90.3%) agreed that diagnostics were helpful for clinical management, they reported patients being unwilling to provide samples and long laboratory turnaround times. Routine diagnostic data represent cases with chronic diarrhoea and dysentery since doctors are most likely to submit specimens for these cases. Pathogen yield (number of pathogens detected for samples tested for specific pathogens) was significantly higher in the surveillance study, which used molecular methods, than through routine diagnostic services (73.3% versus 8.2%, p < 0.001), including for viruses (48.9% versus 2.6%, p < 0.001), bacteria (40.1% versus 2.2%, p < 0.001) and parasites (16.2% versus 3.6%, p < 0.001). Despite viruses being commonly detected in the surveillance study, viral testing was seldom requested in routine diagnostic investigations. Conclusions Comprehensive diagnostic and treatment guidelines are required for diarrhoeal diseases. These guidelines should be informed by local epidemiological data, where diagnostic testing is reserved for cases most likely to benefit from specific treatment. Optimisation of current diagnostic processes and methods are required for these cases, specifically in terms of minimising turnaround times while maximising diagnostic acumen.

Effective risk communication is essential for outbreak mitigation, as recently highlighted during the coronavirus disease 2019 (COVID-19) pandemic. Hand hygiene is one of the proposed public health interventions to protect against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) acquisition and transmission along with social distancing, improved ventilation, environmental cleaning, and wearing of masks. Improving hand hygiene practices in the community requires an understanding of the socio-behavioural context. This cross-sectional community survey in Soweto identified gaps in hand hygiene, which can inform appropriate messaging at the community level. Only 42% of survey respondents practiced adequate hand hygiene. Tailored educational messaging should be targeted at young adults in particular, and the importance of soap for hand hygiene must be emphasised for all age groups. Risk communication should expand to focus on preventing multiple infectious diseases during and beyond the COVID-19 pandemic.

During routine rotavirus surveillance projects in Cameroon and Cote d'Ivoire, 2 fecal samples collected from 2 children <5 years of age who presented with symptoms of gastroenteritis were found to give anomalous G typing results. These specimens were strongly rotavirus positive by enzyme immunoassay, displayed VP6 subgroup II specificity and long RNA electropherotypes, and were typed as rotavirus serotype G2 with monoclonal antibodies. In addition, the strains were typed as rotavirus VP7 genotype G3 and VP4 genotype P[8] by reverse-transcription polymerase chain reaction. Further investigation of the polymerase chain reaction Gtyping results with a second set of primers revealed that the specimens were not genotype G3, and both samples were sequenced to elucidate the problem. Both strains were found to be genotype G10 by nucleotide sequence. Comparison of nucleotide and amino acid sequences and phylogenetic analysis of the African G10 strains revealed that these strains are closely related to the human G10 strains that were detected during the 2001–2003 rotavirus season in Ghana. The detection of G10 rotavirus in Africa adds to the global distribution of this strain and strengthens the need to continue strain surveillance in developing countries to understand the extent of strain distribution and diversity.

The African Rotavirus Network organised the 12th African Rotavirus Symposium (ARS) from 30 July to 1 August 2019 in Johannesburg, South Africa. The symposium theme “A decade of rotavirus vaccination in Africa - Saving lives and changing the face of diarrhoeal diseases”, included sessions aimed at sharing ideas and expertise on prevention and control of diarrhoeal disease in Africa. Inter alia, the delegates reviewed global and regional epidemiological trends on rotavirus diarrhoea, progress and experiences on rotavirus vaccine introduction, including vaccine safety monitoring and impact in Africa, scientific advances in developing newer rotavirus vaccines, surveillance and research on other diarrhoeal pathogens, and providing an enabling environment for networking. Importantly, the 12th ARS served to commemorate the 20th anniversary of the African Rotavirus Network (AfrRN) coinciding with the 50th anniversary of the South African Medical Research Council. Four oral, live-attenuated rotavirus vaccines are currently prequalified by the WHO (Rotarix, RotaTeq, Rotavac and RotaSiil). African countries utilising rotavirus vaccines in routine national immunisation programmes are realising their effectiveness and impact on diarrhoeal disease morbidity. An ~40% reduction in hospitalisations of <5-year-olds with acute gastroenteritis following rotavirus vaccine introduction, was reported between 2006 and 2018 in 92,000 children from the WHO-coordinated African Rotavirus Surveillance Network (AfrRSN) comprising 33 Member States. This was corroborated by a meta-analysis of published data, sourced from January 2000 to August 2018 that reported substantial reductions in rotavirus hospitalisations in countries using rotavirus vaccines. However, it was highlighted that the transition of some countries from Gavi-eligibility and vaccine supply shortfalls present significant challenges to achieving the full impact of rotavirus immunization in Africa. The wide diversity of rotavirus genotypes continues in Africa, with variation observed both geographically and temporally. There is currently no evidence to suggest that the emergence of rotavirus strains not included in the current vaccines do escape vaccine-induced immunity.

There is no doubt that the Global Enteric Multicenter Study (GEMS) has not only revolutionised understanding of diarrhoeal diseases in the young and vulnerable in some of the most disadvantaged areas of the world, but it has also altered the standard by which such studies are to be done going forward. Undoubtedly, for data such as these to be meaningful, controls and cases must be included.

► Acute severe dehydrating rotavirus diarrhoea remains an important contributor towards childhood mortality and morbidity and has been well documented in South Africa. ► South Africa is the first country in the WHO African Region to adopt the rotavirus vaccine in the national childhood immunisation programme in August 2009. ► Studies which facilitated the introduction of rotavirus vaccine in South Africa included the burden of rotavirus disease and strain surveillance, economic burden of rotavirus infection and clinical trials to assess the safety and efficacy of vaccine candidates. ► There is early positive impact of vaccination in reducing the rotavirus burden of disease based on the post-marketing surveillance studies at Dr George Mukhari hospital. Diarrhoeal diseases are ranked the third major cause of childhood mortality in South African children less than 5years, where the majority of deaths are among black children. Acute severe dehydrating rotavirus diarrhoea remains an important contributor towards childhood mortality and morbidity and has been well documented in South Africa. As the preventive strategy to control rotavirus diarrhoea, South Africa became the first country in the WHO African Region to adopt the rotavirus vaccine in the national childhood immunisation programme in August 2009. The rotavirus vaccine in use, Rotarix®, GSK Biologicals, is given at 6 and 14weeks of age, along with other vaccines as part of Expanded Programme on Immunisation (EPI). Studies which facilitated the introduction of rotavirus vaccine in South Africa included the burden of rotavirus disease and strain surveillance, economic burden of rotavirus infection and clinical trials to assess the safety and efficacy of vaccine candidates. This paper reviews the epidemiology of rotavirus in South Africa, outlines some of the steps followed to introduce rotavirus vaccine in the EPI, and highlights the early positive impact of vaccination in reducing the rotavirus burden of disease based on the post-marketing surveillance studies at Dr George Mukhari hospital, a sentinel site at University of Limpopo teaching hospital in Pretoria, South Africa, which has conducted rotavirus surveillance for >20years.

AbstractThe African Rotavirus Network organised the 12 th African Rotavirus Symposium (ARS) from 30 July to 1 August 2019 in Johannesburg, South Africa. The symposium theme “ A decade of rotavirus vaccination in Africa - Saving lives and changing the face of diarrhoeal diseases”, included sessions aimed at sharing ideas and expertise on prevention and control of diarrhoeal disease in Africa. Inter alia, the delegates reviewed global and regional epidemiological trends on rotavirus diarrhoea, progress and experiences on rotavirus vaccine introduction, including vaccine safety monitoring and impact in Africa, scientific advances in developing newer rotavirus vaccines, surveillance and research on other diarrhoeal pathogens, and providing an enabling environment for networking. Importantly, the 12 th ARS served to commemorate the 20 th anniversary of the African Rotavirus Network (AfrRN) coinciding with the 50th anniversary of the South African Medical Research Council. Four oral, live-attenuated rotavirus vaccines are currently prequalified by the WHO (Rotarix, RotaTeq, Rotavac and RotaSiil). African countries utilising rotavirus vaccines in routine national immunisation programmes are realising their effectiveness and impact on diarrhoeal disease morbidity. An ~40% reduction in hospitalisations of <5-year-olds with acute gastroenteritis following rotavirus vaccine introduction, was reported between 2006 and 2018 in 92,000 children from the WHO-coordinated African Rotavirus Surveillance Network (AfrRSN) comprising 33 Member States. This was corroborated by a meta-analysis of published data, sourced from January 2000 to August 2018 that reported substantial reductions in rotavirus hospitalisations in countries using rotavirus vaccines. However, it was highlighted that the transition of some countries from Gavi-eligibility and vaccine supply shortfalls present significant challenges to achieving the full impact of rotavirus immunization in Africa. The wide diversity of rotavirus genotypes continues in Africa, with variation observed both geographically and temporally. There is currently no evidence to suggest that the emergence of rotavirus strains not included in the current vaccines do escape vaccine-induced immunity.