The Current situation with the Rotavirus Vaccine- The Advanced Pediatrics Perspective

The Current situation with the Rotavirus Vaccine:

Not a very dangerous illness

Norovirus is taking the place of Rotavirus

Vaccine carries some risk

Rotavirus was the #1 cause of stomach flu in the United States prior to the introduction of a vaccine to prevent this infection in 2007.  Prior to the development of the vaccine for rotavirus, this virus would sweep across our region every year sometime in February and disappear sometime in the summer.

Rotavirus infection is no fun, it causes vomiting, diarrhea, and stomach upset.  It is the stomach flu that almost everyone has experienced, unpleasant, uncomfortable.  The vomiting and diarrhea can lead to enough loss of fluid to require IV hydration.  For most children, the rotavirus stomach flu is unpleasant, but fluids can be given at home and no need for an IV develops.  For some, IV fluid is needed, and for a very few, enough IV fluid is needed that a brief stay in the hospital occurs.

More rarely, rotavirus infection can cause the intestine to telescope.  Think of the intestine as a long tube and imagine one segment sliding over the next segment, like a telescope can do.   When that happens the gut gets very swollen and can even become blocked or act blocked.  That situation goes by the difficult to spell and pronounce name of intussusception.   

In our own experience with rotavirus, we have been able to monitor the impact of this infection in families who come to Advanced Pediatrics over the last 10 years.  During this period the vast majority of children in the practice have experienced rotavirus stomach flu, and many dozen have had to go to the ER for IV fluids to be given over a several hour period.  Less than a dozen have needed IV fluid for long enough to require a day or so in the hospital, and even fewer have developed intussusception.  During this time period, essentially single child in the practice who has had a stomach flu infection has had a full, complete, and uncomplicated recovery- to the best of our knowledge.

So, given this experience, we have studied whether offering rotavirus vaccination would be, overall, a benefit to the families at Advanced Pediatrics.

There are three reasons why it might not offer much benefit:

1.  The actual infection the vaccine is trying to prevent is too minor to detect much benefit.

2.  The vaccine may carry side effects that make the situation worse.

3.  Eliminating rotavirus may become irrelevant if another stomach flu virus takes its place.

The first rotavirus vaccine came out in the 1990's, and our first response was that the actual experience of stomach flu was to mild that even if the vaccine had very rare but serious side effects, a child was better off not getting it, so we held off recommending its use.  Not long after it was found that that first version of the rotavirus vaccine indeed caused a jump in the chance of the child's bowel obstructing via the condition of intussusception, described above.   That vaccine was taken off the market.

In 2007, a second version of the rotavirus vaccine was introduced.  At Advanced Pediatrics we came to our earlier conclusion.  Namely, since no child in the practice with stomach flu had ever suffered a serious consequence, it made sense to be sure that this new version of a vaccine be observed, to make sure it too did not turn out to be harmful enough to be taken off the market.

Fortunately, this time, the vaccine did not cause enough of an increase in the rates of intussusception to be taken off the market, and no other serious side effects have emerged over the last 6 years.

This month, June of 2013, a major paper on the chance of developing intussusception after use of this and a third and newest rotavirus vaccine was published.   Together with other studies, we now have a clearer picture of whether getting the rotavirus vaccine raises risk or lowers it, and if the lower risk is sufficient to justify its use.

What the studies have found is that for infant ages 8-11 weeks, which is the age the first dose of rotavirus vaccine is to be given, the chance of intussusception does increase over the chance of getting it if you are not vaccinated.  The chances are remote in either case, the rates are per 100,000 infants.  But if you are not vaccinated the chance of being admitted to a hospital for intussusception is about 7 per 100,000 infants, and if you are vaccinated the risk goes up to 11.5.

So the risk of intussusception is increased if you get the rotavirus vaccine, not by much, but by some.

A second trend has also emerged, and that is the appearance of the norovirus.  Noroviruses are famous as the cause of cruise-ship stomach flu epidemics, but they are also the #1 cause of food related illness with an incubation period of about 12 hours.  

About 85% of American infants have become vaccinated for rotavirus, but norovirus has stepped into the gap and now causes more stomach flu than any other virus.  In fact, there is so much norovirus around that even if you are vaccinated for rotavirus, you are just about as likely to get stomach flu.  The drop in rotavirus stomach flu has been matched by the rise in norovirus stomach flu.

BOTTOM LINE

Putting it all together the case for using the rotavirus vaccine seems quite weak:

Our experience with stomach flu is reassuring

No lasting harm from a case of stomach flu has occurred

Norovirus has replaced rotavirus

Giving the rotavirus vaccine will have little impact on the chance of your child getting stomach flu.

Intussusception risk

A large body of data from the last 6 years establishes that getting the rotavirus vaccine increases the chance that your child will develop intussusception- a process that can cause bowel obstruction.

Not much protection from getting stomach flu and an increased risk of a serious complication combine to lead us to continue recommend against the routine use of rotavirus immunization at Advanced Pediatrics.   The American Academy of Pediatrics and Centers for Disease Control both do recommend universal use of rotavirus vaccine in early infancy, and so we do make the vaccine available, and remain happy to discuss the topic.

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