title: Impact of rotavirus vaccination on diarrhea-related hospitalizations in São Paulo State, Brazil.
abstract: BACKGROUND
  Following introduction of routine infant rotavirus vaccination, severe diarrhea hospitalization rates declined among children aged <5 years throughout Brazil. Ensuring equity of rotavirus vaccine impact is important in countries that self-finance immunization programs. The objective of this study was to examine rotavirus vaccine impact on diarrhea admission rates among children aged <5 years in Brazil's public health system, according to area-based measures of human development in the state of São Paulo, Brazil.
  
  
  METHODS
  Ecological analysis of public health system hospitalization rates for acute gastroenteritis among children aged <5 years in the state of São Paulo, Brazil, according to five categories of municipal development based on a modified Human Development Index for municipalities. Acute gastroenteritis hospitalization rates among children aged <5 years after national rotavirus vaccine introduction (2008-2011) were compared to rates in pre-vaccine years (2000-2005) to calculate percent decline in rates (1-rate ratio) and 95% confidence intervals (CI) for each municipal development category. Direct hospitalization costs during the two periods were compared.
  
  
  RESULTS
  Annual rates declined by 40% (95% CI, 39-42%) from 631 diarrhea hospitalizations per 100,000 person years pre-rotavirus vaccination to 377 per 100,000 post-vaccination among children aged <5 years and 50% (95% CI, 48-52%) from 1009 to 505 per 100,000 among infants. Highest rates were observed in least developed municipalities. Significant declines of 26-52% among children <5 years and 41-63% among infants were observed in all categories of municipal development. Lower diarrhea hospitalization rates resulted in annual savings of approximately 2 million USD for the state of São Paulo. Savings in direct hospitalization costs benefitted municipalities in all five categories.
  
  
  CONCLUSIONS
  The introduction of rotavirus vaccination was associated with substantial reductions of diarrhea-related admissions at all levels of municipal development in São Paulo State, Brazil.
authors.affiliation: Field Epidemiology Training Program/São Paulo State (EPISUS-SP), Secretaria de Estado da Saúde de São Paulo, Avenida Dr Arnaldo, 35, 6th floor, São Paulo, SP 01246-000, Brazil. Electronic address: edergatti@hotmail.com.br.
authors.forename: Eder Gatti
authors.initials: EG
authors.lastname: Fernandes
authors.affiliation: Division of Immunization, São Paulo State Health Department, Avenida Dr Arnaldo, 35, 6th floor, São Paulo, SP 01246-000, Brazil. Electronic address: hsato@saude.sp.gov.br.
authors.forename: Helena Keico
authors.initials: HK
authors.lastname: Sato
authors.affiliation: Epidemic Intelligence Service, Office of Workforce and Career Development, Centers for Diseases Control and Prevention, 1600 Clifton Rd, MS A-34, Atlanta, GA 30333, United States. Electronic address: wgp9@cdc.gov.
authors.forename: Eyal
authors.initials: E
authors.lastname: Leshem
authors.affiliation: Centers for Diseases Control and Prevention, 1600 Clifton Rd, Atlanta, GA 30333, United States. Electronic address: bif4@cdc.gov.br.
authors.forename: Brendan
authors.initials: B
authors.lastname: Flannery
authors.affiliation: Field Epidemiology Training Program/São Paulo State (EPISUS-SP), Secretaria de Estado da Saúde de São Paulo, Avenida Dr Arnaldo, 35, 6th floor, São Paulo, SP 01246-000, Brazil. Electronic address: tcroma@saude.sp.gov.br.
authors.forename: Thais Claudia Roma de Oliveira
authors.initials: TC
authors.lastname: Konstantyner
authors.affiliation: Departamento de Medicina Social, Faculdade de Ciências Médicas da Santa Casa de São Paulo, Rua Dr. Cesário Mota Jr., 61, 6th floor, São Paulo, SP 01221-020, Brazil. Electronic address: maria.veras@gmail.com.
authors.forename: Maria Amélia de Sousa Mascena
authors.initials: MA
authors.lastname: Veras
authors.affiliation: Division of Viral Diseases, Centers for Diseases Control and Prevention, 1600 Clifton Rd, MS A-34, Atlanta, GA 30333, United States. Electronic address: aul3@cdc.gov.
authors.forename: Manish M
authors.initials: MM
authors.lastname: Patel
mesh_terms: D001938:Brazil / Q000453:epidemiology; D002675:Child, Preschool; D003967:Diarrhea / Q000453:epidemiology / Q000517:prevention & control* / Q000821:virology; D005759:Gastroenteritis / Q000453:epidemiology / Q000517:prevention & control* / Q000821:virology; D006760:Hospitalization / Q000191:economics / Q000706:statistics & numerical data*; D006801:Humans; D007223:Infant; D012401:Rotavirus; D012400:Rotavirus Infections / Q000453:epidemiology / Q000517:prevention & control*; D022243:Rotavirus Vaccines / Q000627:therapeutic use*
chemical_list: D022243:Rotavirus Vaccines
keywords: Brazil; Diarrhea; Rotavirus; Vaccine