In the JournalsPerspective

Rotavirus recommendations leave NICU population vulnerable, study finds

Andi Shane
Andi L. Shane

The CDC’s Advisory Committee on Immunization Practices cautions against administering the rotavirus vaccine to infants in a NICU or nursery because of the potential for horizontal transmission of the live vaccine-strain virus. It also recommends age restrictions on the timing of the rotavirus vaccine, with the first dose to be given before 15 weeks of age. These intersecting recommendations create a vulnerable population of infants who require a prolonged intensive care stay and might age out of vaccine eligibility, according to a study published in the Journal of the Pediatric Infectious Diseases Society.

“In this paper, we describe a rotavirus outbreak that affected nearly all resident patients at a subacute care facility,” Rachel M. Burke, an epidemiologist in the CDC’s Viral Gastroenteritis Branch, told Infectious Diseases in Children. “Most children were unvaccinated against rotavirus; a number of these had aged out of eligibility due to prolonged stays in intensive care — where live vaccines are discouraged — while others missed the opportunity to be vaccinated while they were still age-eligible.”

The outbreak resulted in one fatality and serves as an example of the “potential consequences of low rotavirus vaccine coverage among medically fragile children,” Burke added.

Burke and colleagues reviewed the clinical history, vaccination history and signs and symptoms of 26 patients (median age, 2.9 years) in the facility during the outbreak. They defined case-patients as those who experienced three or more loose stools within 24 hours, with onset between April 2017 and May 2017. They used reverse-transcription PCR to test patient stool samples for rotavirus.

A total of 22 (85%) of the patients met the case definition, 15 were unvaccinated, three were partially vaccinated, two were fully vaccinated and 11 tested positive for rotavirus.

“Vaccination is the best means of preventing severe rotavirus-associated outcomes,” Burke said. “Clinicians should be vigilant in pursuing rotavirus vaccination in a timely manner for all eligible infants, with special focus on infants who may otherwise miss the opportunity to be vaccinated — such as infants approaching the age-eligibility window or age-eligible infants being discharged from intensive care units.”

In a related editorial, Infectious Diseases in Children Andi L. Shane, MD, MPH, MSc, associate professor of pediatrics at Emory University School of Medicine and Children's Healthcare in Atlanta, and Geoffrey A. Weinberg, MD, professor of pediatrics and clinical director of the Pediatric Infectious Diseases & Pediatric HIV Program at the University of Rochester School of Medicine & Dentistry and Golisano Children’s Hospital, argued that stringent age-restricting recommendations for rotavirus vaccine are unwarranted.

“We encourage the [ACIP] to adopt a strategy to relax age limitations on the administration of rotavirus vaccine similar to that of the World Health Organization, which permits rotavirus vaccine doses to be administered to children between 6 weeks and 24 months of age,” they wrote. – by Joe Gramigna

Disclosures: The authors report no relevant financial disclosures.

Andi Shane
Andi L. Shane

The CDC’s Advisory Committee on Immunization Practices cautions against administering the rotavirus vaccine to infants in a NICU or nursery because of the potential for horizontal transmission of the live vaccine-strain virus. It also recommends age restrictions on the timing of the rotavirus vaccine, with the first dose to be given before 15 weeks of age. These intersecting recommendations create a vulnerable population of infants who require a prolonged intensive care stay and might age out of vaccine eligibility, according to a study published in the Journal of the Pediatric Infectious Diseases Society.

“In this paper, we describe a rotavirus outbreak that affected nearly all resident patients at a subacute care facility,” Rachel M. Burke, an epidemiologist in the CDC’s Viral Gastroenteritis Branch, told Infectious Diseases in Children. “Most children were unvaccinated against rotavirus; a number of these had aged out of eligibility due to prolonged stays in intensive care — where live vaccines are discouraged — while others missed the opportunity to be vaccinated while they were still age-eligible.”

The outbreak resulted in one fatality and serves as an example of the “potential consequences of low rotavirus vaccine coverage among medically fragile children,” Burke added.

Burke and colleagues reviewed the clinical history, vaccination history and signs and symptoms of 26 patients (median age, 2.9 years) in the facility during the outbreak. They defined case-patients as those who experienced three or more loose stools within 24 hours, with onset between April 2017 and May 2017. They used reverse-transcription PCR to test patient stool samples for rotavirus.

A total of 22 (85%) of the patients met the case definition, 15 were unvaccinated, three were partially vaccinated, two were fully vaccinated and 11 tested positive for rotavirus.

“Vaccination is the best means of preventing severe rotavirus-associated outcomes,” Burke said. “Clinicians should be vigilant in pursuing rotavirus vaccination in a timely manner for all eligible infants, with special focus on infants who may otherwise miss the opportunity to be vaccinated — such as infants approaching the age-eligibility window or age-eligible infants being discharged from intensive care units.”

In a related editorial, Infectious Diseases in Children Andi L. Shane, MD, MPH, MSc, associate professor of pediatrics at Emory University School of Medicine and Children's Healthcare in Atlanta, and Geoffrey A. Weinberg, MD, professor of pediatrics and clinical director of the Pediatric Infectious Diseases & Pediatric HIV Program at the University of Rochester School of Medicine & Dentistry and Golisano Children’s Hospital, argued that stringent age-restricting recommendations for rotavirus vaccine are unwarranted.

“We encourage the [ACIP] to adopt a strategy to relax age limitations on the administration of rotavirus vaccine similar to that of the World Health Organization, which permits rotavirus vaccine doses to be administered to children between 6 weeks and 24 months of age,” they wrote. – by Joe Gramigna

Disclosures: The authors report no relevant financial disclosures.

    Perspective
    Janet A. Englund

    Janet A. Englund

    Rotavirus vaccine has decreased the overall incidence of rotavirus disease in the United States and is now widely integrated into the U.S. pediatric immunization schedule. Although premature infants are at increased risk for severe disease, they continue to be undervaccinated against rotavirus, as reported by Hofstetter and colleagues in Pediatrics. This is due in part to the 2009 ACIP recommendations that rotavirus vaccines should not be administered in inpatient hospital settings. Recent data from the U.S. and internationally have demonstrated that the spread of rotavirus vaccine strains within institutions using standard infection control practices have not occurred and that spread of rotavirus vaccine strains even in family settings are uncommon.

    The outbreak reported by Burke and colleagues describes the impact of undervaccination of children with underlying medical conditions in an institutional setting. Children who are hospitalized during the first several months of life might be too old to receive rotavirus vaccine when they are discharged. Restriction of rotavirus vaccine to settings outside the hospital likely contributed to the rotavirus outbreak described. In view of new data regarding rotavirus vaccine safety and spreading in preterm infants, the serious consequences of not vaccinating young children at risk for severe rotavirus disease needs to be strongly considered.

    References:

    Cortese MM, et al. MMWR Recomm Rep. 2019;doi:58(RR02);1-25.

    Hofstetter AM, et al. Pediatrics. 2019;doi:10.1542/peds.2017-1110.

    • Janet A. Englund, MD
    • Professor of pediatric infectious diseases
      Seattle Children’s Hospital
      Professor of pediatrics
      University of Washington School of Medicine

    Disclosures: Englund reports working as a consultant for Sanofi Pasteur and Meissa Vaccines. She reports research support to her institution from MedImmune, Novavax, Merck, Chimerix and GlaxoSmithKline.