Our estimate of rotavirus outpatient visits are lower than those estimated by Parashar and colleagues [8] and [9] because a conservative ratio of rotavirus outpatient visits to hospitalization obtained from a phase III rotavirus vaccine trial cohort of 1500 children observed for two years was used in which two-thirds of children had received a rotavirus vaccine. The ratio of outpatient rotavirus gastroenteritis visits to rotavirus gastroenteritis

admission in the phase III clinical trial population was 3.75, and may have been lower because of the prompt administration of rehydration solutions at home decreasing mild or moderate disease, which points again to higher need for healthcare due to rotavirus disease than has previously been estimated. These are findings Romidepsin that must be considered as policy makers shift from impact estimation based on mortality alone to disease reduction. This study has several limitations.

First, four of the five cohorts that contributed to the estimation of rotavirus related morbidity were from a single site in Vellore. It is likely that morbidity rates and health-seeking characteristics of this population differs from higher mortality Lumacaftor nmr regions of India and limits the validity of extrapolations from these geographically limited cohorts. Nonetheless, given that health characteristics and health care access in Tamil Nadu are better than most other parts of India, it is likely that the estimates based on Tami Nadu are very conservative. Second, the <5 mortality rate is the number of <5 deaths per 1000 live births in a year and does not provide a direct estimate of probability of death between 0 and 5 years required for calculating deaths averted and NNV. Third, there is limited information on the rate of rotavirus morbidity in the 3–5 year age group. This analysis assumes a constant rate of events in the 4 months to 2 years age group Levetiracetam and applies an adjusted estimate to the 3–5 year age group where no or limited direct estimates are available. Similarly we applied the ratio of outpatient to inpatient rotavirus gastroenteritis

among the clinical trial participants to estimate the number of ambulatory rotavirus gastroenteritis visits. Despite there being no active referral to hospital for diarrheal episodes, free and better healthcare access in the clinical trial environment could have inflated the number of outpatient visits. This must be considered against the underestimation of the impact on society due to rotavirus disease that occurs when outpatient and hospitalization rates do not account for barriers in access to appropriate levels of healthcare. Furthermore, the increased access to ambulatory care might, by early diagnosis and treatment, prevent progression of disease to more severe presentation and thus contribute to lower estimates of mortality and hospitalization. Fourth, this analysis assumes that vaccine efficacy approximates effectiveness.