Effect of rotavirus vaccination on the burden of rotavirus disease and associated antibiotic use in India: A dynamic agent-based simulation analysis

Background: Rotavirus is a leading cause of diarrhea in infants and young children in many low- and middle-income countries. India launched a childhood immunization program for rotavirus in 2016, starting with four states and expanding it to cover all states by 2019. The objective of this study was to estimate the effects of the rotavirus vaccination program in India on disease burden and antibiotic misuse. Methods: We built a dynamic agent-based model of rotavirus progression in children under five within each district in India. Simulations were run for various scenarios of vaccination coverage in the context of India's Universal Immunization Programme. Population data were obtained from the National Family Household Surveys and used to calibrate the models. Disease parameters were obtained from published studies. We estimated past and projected future reduction of disease burden and antibiotic misuse due to full vaccination nationwide, by state, and by wealth quintile. Results: We estimate that rotavirus vaccination in India has reduced the prevalence of rotavirus cases by 33.7% (prediction interval: 30.7–36.0%), total antibiotic misuse due to rotavirus by 21.8% (18.6–25.1%), and total deaths due to rotavirus by 38.3% (31.3–44.4%) for children under five. We estimate total antibiotic misuse due to rotavirus infection to be 7.6% (7.5–7.9%) of total antibiotic consumption in this demographic versus 9.6% (9.4–9.9%) in the absence of vaccination. We project rotaviral prevalence to drop to below one case for every 100,000 individuals in those below five if vaccination coverage is increased by 50.3% (45.2–58.5%) to 68.1% (63.1–76.4) nationwide. Conclusion: Universal coverage of childhood rotavirus vaccination can substantially reduce inappropriate antibiotic use in India.