This might be because there were few undiagnosed rotavirus AGE cases at the clinic due to the high sensitivity of the rotavirus enzyme immunoassay test used on stool. Data from home visits was useful in uncovering how much severe rotavirus gastroenteritis occurred in the community. Using PRV as a probe for severe rotavirus gastroenteritis in the community, we found that over 40% of gastroenteritis with severe dehydration in Kenyan infants was likely due to rotavirus. This prevalence is similar to that seen among

children hospitalized with acute gastroenteritis in other African settings; the WHO Ibrutinib cell line rotavirus surveillance network reported from 8 African countries on average 40% of stools from hospitalized gastroenteritis episodes

were positive for rotavirus, ranging from 29 to 52% [21]. Vaccines have been used before as probes to uncover hidden disease burden buy Tenofovir among outcomes that cannot be confirmed by laboratory diagnosis [22] and [23]. Vaccines used as probes can be particularly illuminating of disease burden when the outcome being measured is non-specific or when laboratory diagnosis identifies only a fraction of cases either due to low sensitivity lab tests (e.g. blood cultures for pneumococcal pneumonia) or where there is limited access to facilities where a diagnosis can be made (e.g. rural Africa), which was the case in this trial [22]. In this study, the home-visit data revealed that most severe rotavirus gastroenteritis was likely not identified at health facilities by the clinic-based catchment surveillance. In the first year of life, the decrease in incidence of gastroenteritis with severe dehydration in the community (19.0 cases per 100 person-years) was almost six times greater than the reduction in severe RVGE presenting to the clinic (3.3 per 100 person-years.) As such, the greatest public health impact of PRV in 3-mercaptopyruvate sulfurtransferase rural Africa is likely prevention of episodes of severe RVGE, including rotavirus-related deaths, which occur in the community and never reach a health facility (where life-saving rehydration would be most likely to occur). This is because health-seeking for acute illnesses,

including diarrhea, remains low in rural Africa. A recent health utilization survey in a neighboring district in rural western Kenya revealed that only 36% of children with a severe diarrhea are taken to a health facility for treatment [24]. Moreover, in this part of rural Kenya, as in most high-mortality African settings, most childhood deaths, approximately two-thirds, occur at home, suggesting that care-seeking even for the most severe illnesses is limited ([25], KEMRI/CDC unpublished data). Health facility utilization in rural Africa is hampered by multiple factors, including the cost of transport and care, distance to the facility, frequent stock-outs of medications, and perceived variable quality of care [26], [27], [28] and [29].