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Rotavirus infections in children: clinical picture and principles of prevention

doctor. Agnieszka Kwiecień, specialist in family medicine

You can read this text in 6 min.

Rotavirus infections in children: clinical picture and principles of prevention

PantherMedia

Virus

Discussion of the epidemiology and clinical picture of rotavirus infections and current recommendations for rotavirus vaccination.

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Table of contents:

  1. Epidemiology
  2. Clinical picture
  3. Rotavirus vaccines
  4. Efficacy and safety of use
  5. Recommendations for rotavirus vaccination
  6. Contraindications to vaccination
  7. Routine infant vaccination schedule
  8. Choice of vaccine
  9. Special situations

Epidemiology

Rotaviruses are one of the most common causes of acute gastroenteritis in children in the first 3-5 years of life. It is estimated that by the age of 5 years, 80% of children have a rotavirus infection. In 1 in 7 sick children, symptoms are so severe that they require urgent medical attention. 1 in 70 sick children require hospitalisation. There are even fatalities in the course of rotavirus infections, which, for example in the USA, are estimated to be around 1 in 200,000 cases.

The typical period of the most frequent incidence is from late autumn to early spring. The serological structure of the virus makes it possible for a child who has already had one rotavirus infection to be re-infected with a different strain of the virus. Infections spread very easily in communities of children, as there are very many virus particles in the faeces of an infected person (100 billion per gram of faeces!) and infectivity occurs even before the first symptoms of the disease appear.

Rotaviruses tend to cause illness with a more turbulent course than other viruses infecting the gastrointestinal tract of children. Clinical studies show that rotavirus aetiology accounts for as much as 30-50% of causes of diarrhoea among children requiring hospitalisation for acute gastroenteritis. A reduction in rotavirus infections is therefore potentially of great benefit to both child health and the healthcare system.

Clinical picture

The incubation period is short, ranging from 1 to 3 days. Symptoms start acutely - usually with fever and vomiting. Particularly typical are persistent vomiting at the beginning of the disease, which precedes the onset of diarrhoea by 24-48 hours. Prodromal symptoms of upper respiratory tract rhinitis are possible. The fever is quite high, exceeding 39 degrees in one third of children. Symptoms of gastroenteritis usually last from 3 to 8 days. Diarrhoea is usually watery, with a high number of bowel movements per day (10-20). Admixture of blood in the stools is possible, as well as signs of dehydration and dyselectrolyaemia.

In ancillary investigations, despite being a viral infection, elevated ESR and CRP values are encountered. A large proportion of children with rotavirus infection have a transient increase in aminotransferases (AST and ALT). This is not indicative of complications of the disease and does not require special management. The aminotransferase values normalise with the resolution of the underlying disease.

Diarrhoea, Rotarix, Rotateq, Rotavirus, VaccinationsRotavirus in children, photo: panthermedia

Rotavirus vaccines

Attempts to introduce an effective and safe rotavirus vaccine into clinical practice date back to the 1980s. There was even a Rotashield vaccine put into practice, but this was withdrawn due to reports of side effects - an increase in the incidence of intestinal intussusception was observed in vaccinated children.

In recent years, clinical trials have been completed and two new-generation vaccines have been authorised, which appear to be free of side effects. These are: Rotarix (containing the live, attenuated human virus strain RIX4414, produced on the Vero cell line) and Rotateq (containing a so-called reassortant of five human and bovine strains). Both are intended for oral use. Rotateq requires three doses of the vaccine, Rotarix has been registered in a two-dose schedule.

Efficacy and safety of use

Clinical trials have shown a very high efficacy of the vaccine in preventing illness (about 74% overall) and, in particular, an almost 100% efficacy in preventing severe illness requiring hospitalisation. When used concomitantly with other vaccines, no reduction in the efficacy of these vaccines has been shown following an additional oral dose of Rotarix or Rotateq. Also, the type of feeding (natural or artificial) did not affect the immunization effect. There are quite limited data on vaccination in children born before 37 weeks of gestation, but the available results on small groups of children born between 25 and 36 weeks of gestation, suggest an efficacy of about 70%, which is similar to that of term babies.

Evaluation of side effects has been done in large population-based studies involving groups of up to more than 70,000 children. No increased incidence of intestinal intussusception or other serious side effects has been demonstrated. This applies to studies in both term and preterm infants. The most common side effects after vaccination are irritability of the child and a temporary lack of appetite, as well as (less frequently) mild diarrhoea, abdominal bloating or returning food.

Recommendations for rotavirus vaccination

Currently, most global expert groups, led by the American Academy of Pediatrics (AAP), recommend rotavirus vaccination as a routine vaccination for every healthy infant. The rationale for this position is:

  • the high efficacy of the vaccine,
  • the safety of the vaccine,
  • clear health and economic benefits in populations with universal vaccination.

Contraindications to vaccination

The main contraindication is possible severe hypersensitivity to a previously administered dose of rotavirus vaccine. As with other live vaccines, special care should be taken in children with primary and secondary immunodeficiencies. A temporary contraindication is current ongoing gastroenteritis or other acute infectious disease. Caution is also advised in children following an incident of intussusception, or with a confirmed gastrointestinal defect favouring intussusception.

Vaccination should not be started in children older than 12 weeks. The idea is to complete the vaccination cycle before 24 weeks for Rotarix or before 32 weeks for Rotateq. Administration of the vaccine in children older than 24-32 weeks may increase the risk of gastrointestinal side effects.

Routine vaccination schedule for infants

The optimum age for starting vaccination is 6-12 weeks, together with DTP vaccination and any additional vaccinations (HiB, pneumococcal).

When administering Rotateq, it is recommended that 3 oral doses are given at intervals of 4-10 weeks, so that the cycle of three vaccinations is completed by 32 weeks of age at the latest.

When administering Rotarix, it is recommended that 2 oral doses be given at an interval of at least 4 weeks so that the second dose is given by 24 weeks of age at the latest (optimum time for the second dose given by the manufacturer - before 16 weeks of age)

Choice of vaccine

There are no data to justify the superiority of one type of vaccine over the other. Both preparations (Rotarix and Rotateq) should be treated equally. The choice of preparation is up to the doctor.

Special situations

  1. No significant interactions with other vaccines have been demonstrated. In particular, it has been studied that rotavirus vaccines can be given concomitantly with DTaP, HiB, IPV, HBV and meningococcal and pneumococcal vaccines.
  2. Babiesborn prematurely can be vac cinated - the same schedule as for babies born at term is recommended, provided the baby is stable, without disease burden and is at least 6 weeks old.
  3. Children living in a shared household with immunocompromised persons can be vaccinated. It is only recommended that persons in contact with the child's faeces carefully wash their hands for approximately 1 week after the first dose of vaccine.
  4. Children living in a shared household with pregnant women can be vaccinated.
  5. If a child returns or spits up most of the vaccine immediately after oral administration,it is permissibleto administer an additional single replacement dose at the same visit. Experts emphasise, however, that this depends on individual circumstances, and in general there are no data on the effects of administering a dose lower or higher than that contained in the standard vaccine.
  6. If a newly vaccinated child has been hospitalised, there is no need to take special measures with regard to possible spread of the vaccine virus.