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 article info Article history: Available online xxxx Keywords: Diarrhea Children under five Rotavirus vaccine Indonesia abstract Context: Rotavirus diarrhea is a common disease worldwide which mostly affects children under five 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 the National Immunization Program. This study aims to describe the proportion of rotavirus in children under 5 in Indonesia, the clinical characteristics of rotavirus infections, and the rotavirus strains circulat- ing in the country during 2010–2015. Methods: Children under five years of age with acute watery diarrhea were prospectively identified and 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 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. ⇑ 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). Vaccine xxx (2018) xxx–xxx Contents lists available at ScienceDirect Vaccine journal homepage: www.elsevier.com/locate/vaccine 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