The report contains no information about rotavirus serotypes

The report contains no information about rotavirus serotypes in Rwanda. This is not that important though because for practical purposes surveillance of rotavirus serotypes is becoming obsolete as it has been convincingly shown that the efficacy and effectiveness of rotavirus vaccines against severe rotavirus gastroenteritis are not serotype-specific. Thus, the pentavalent and monovalent vaccines are at the same start line. As an example, the 49% efficacy of Rotarix in Malawi was the same against various rotavirus G-types that were recorded during the trial. If the performance of rotavirus vaccines in Africa is not as good as in developed countries, it is not because there are more diverse rotavirus serotypes circulating in Africa. Although the effectiveness of rotavirus vaccine in Rwanda is high and is promising, the effectiveness is still less than in developed countries. For example, in Finland, with equally high coverage, the effect of rotavirus vaccination has been an 88% p53 apoptosis of admittances to hospital for rotavirus gastroenteritis, with most of the remaining cases occurring in older children who have been too old to be vaccinated in the programme, and very few breakthrough cases of severe rotavirus gastroenteritis in vaccinated children, and even those mostly in partially vaccinated children. Such information from Rwanda (and other African countries) is missing, and future studies should address the effectiveness of RotaTeq vaccine after complete and incomplete series of vaccinations. An interesting finding in the study of Ngabo and colleagues was that, after a huge drop in the number of admittances to hospital for rotavirus in 2013, there was no further fall the next year. As the researchers discuss, this finding might herald the beginning of a biennial pattern of rotavirus activity in Africa after universal rotavirus vaccination—a phenomenon that has been seen in the USA for several years. Another epidemiological change in the USA has been a shift of the rotavirus epidemic season towards a later onset. Perhaps the data from Rwanda can be read to suggest that this might be also happening in an African country that has a very clear seasonal pattern of rotavirus activity. Altogether, the experience of the first 2 years of rotavirus vaccination in Rwanda can be summarised as a success. But does this success come at a price? The present report does not even mention intussusception or give any information about compliance with the EPI schedule. The WHO position towards rotavirus vaccination in Africa has been that in the interest of better coverage the timing of the first dose can be extended up to 6 months of age. It is recognised that this could increase the risk of intussusception. It would be important to document how well African countries can adhere to the recommended EPI schedule of 6, 10, and 14 weeks, because, if adhered to, such early administration could rather decrease or even minimise the risk. The report from Rwanda does not address this point, and further information is awaited.
The 1978 Declaration of Alma-Ata on primary health care states that governments have a responsibility for the health of their people that can be fulfilled only by the provision of adequate health and social measures. In Ethiopia, the Health Extension Programme (HEP), run by trained female health extension workers (HEWs) who provide a package of 16 integrated community-based services, forms the pillar of primary health care. Local recruitment and familiarity with the social make-up of their community enable the HEWs to apply tailored approaches to provision of this standard package of services. The HEP has continuously evolved and contributed to the significant progress and achievement in the health sector of the nation. The primary goal of the programme has been training and graduation of model households. Model households refer to families that have embraced locally tailored health behaviour criteria (eg, having children vaccinated, constructing and using latrines, and sleeping under mosquito nets). There is a critical mass of nearly 3 million model households that have graduated over the years. Building on this concept, participatory engagement of women\'s groups to disseminate health information and facilitate uptake of critical health services was initiated in 2012. This movement, commonly referred to as the health development army (HDA), is led by a group of women volunteers who are from model households and complement the work of HEWs and further augment the engagement and leadership of community members in their own health. The HDAs are trained by HEWs and have facilitated sustainable community engagement and ownership, including establishment of community solidarity funds to finance priority challenges identified by the community. For example, by 2015, more than 200 ambulance vehicles were procured through exclusive community financing. Ethiopia has just launched an ambitious 5-year Health Sector Transformation Plan (HSTP). As a progressive evolution of the HEP, the HSTP focuses on the establishment of model “kebeles” (villages) throughout the country. The recognition of kebeles as model will be based on a set of verifiable criteria including at least 80% coverage of model households within their geographic area. Households will be encouraged and monitored to take up tailored and predefined health promotion, disease prevention, and basic curative interventions. High impact interventions will be defined regularly on the basis of national and local priorities and efforts will be exerted to ensure their maximum coverage.