Lancaster County Pediatricians Take Close Look at Rotavirus, How Vaccination Works
Dr. Pia Fenimore
Dr. Joan Thode
One of the changes that the U.S. Department of Health and Human Services recently made to the childhood immunization schedule was to change the vaccine for rotavirus from recommended for all infants to one based on “shared decision-making.”
Since this can be very confusing for parents here is the information, you need to know.
What is it?
Rotavirus is a virus from the Reoviridae family, which gets its name from the Latin word for “wheel” because, under the microscope, the virus appears as a wheel with spokes. It causes fever, vomiting and diarrhea and, in smaller children, can lead to dehydration, seizures and death. Rotavirus in the United States is typically seasonal from December through April, and symptoms last generally from three to eight days.
How does it cause disease?
The virus invades the lining of the stomach and intestines, causing them to become ineffective in absorbing fluids and electrolytes. This leads to high volumes of watery diarrhea and puts the child at risk for severe dehydration. It also causes an activation of the nervous system in the gut; this causes vomiting. The smaller the person, the less fluid reserve and the faster dehydration can occur.
How is it spread?
It is spread through contact with viral particles shed in the stool — that is, poop — of infected individuals. Close contact, which is common among toddlers, or activities such as changing diapers can lead to transmission.
The virus is highly contagious; can survive on surfaces for several days; and requires only a very small exposure to cause infection. Infected people can shed the virus in their stool for up to three weeks.
If this is just a common, mild stomach bug, why do we vaccinate?
It’s common, yes. But mild? No.
This is a very aggressive virus that makes the gut ineffective at absorbing fluids, electrolytes and nutrients; this can lead to rapid dehydration and disruption in levels of potassium and sodium, which are both critical for brain and heart function.
Rotavirus infection has been associated with infant seizures, which may be related to electrolyte disturbances. However, the detection of viral antigen in cerebral and spinal fluid also suggests the virus can infect the central nervous system.
Why do we vaccinate babies?
Babies are particularly vulnerable to consequences of rotavirus infection because their gut and kidneys are very immature and are not yet efficient at managing fluids. Because of their small size, babies dehydrate quickly and can experience rapid organ shutdown related to lack of blood flow and essential electrolytes.
How common was rotavirus before the vaccine?
According to the Centers for Disease Control and Prevention, there were 2.7 million infections and 55,000 to 70,000 hospitalizations per year in the United States in children under the age of 5 before the vaccine was introduced in 2006. And there were 20 to 60 deaths in children under the age of 5 annually in the U.S.
Is the vaccine effective?
Since the vaccine was introduced, there has been an 85% to 95% decline in U.S. hospitalizations for rotavirus. The vaccine is highly protective.
Who should get the vaccine?
Rotavirus vaccination is recommended for infants starting at age 2 months and should be completed between 6 to 8 months. Vaccination for older children is not available.
How is the vaccine given?
Rotavirus vaccination is given orally by gently squeezing the liquid into the inside of the baby’s cheek. This ensures proper production and location of antibodies in the gut where they are needed to combat infection. Typically babies receive three doses to ensure that they have adequate immunity.
Common side effects?
Mild fever and loose stools are common side effects.
Some studies support that there is a rare increase in the incidence of intussusception after vaccination. Intussusception is a sliding of bowel segments into each other that can lead to blockage and bleeding in the gut. Cases are seen in about 1 to 5 per 100,000 infants vaccinated. The bowel condition occurs within one week of vaccination and presents with fussiness and blood in the stool. It is very treatable but can require hospitalization. The risk of intussusception is much lower than the risk of severe rotavirus infection. In fact, the risk of intussusception due to viral infections such as rotavirus is significantly higher than the risk associated with the vaccine.
Do other countries recommend rotavirus vaccination universally?
Yes! According to the World Health Association, some 126 countries — including England, Germany, France, Sweden and Norway — have universal rotavirus vaccination programs.
Does insurance cover rotavirus vaccination?
In Pennsylvania, rotavirus, and all the childhood vaccines, remain covered by most insurances. The commonwealth’s Vaccines for Children program provides free vaccination, including rotavirus, to any child without insurance coverage.
Our experience of rotavirus
Rotavirus was extremely common in the 1990s and 2000s, so many of us cared for a lot of patients with this illness. As residents, we remember how, in early spring, pediatric hospitals would take on an offensive and pervasive aroma — it was the aroma of rotavirus diarrhea, a unique mixing of nutmeg sweetness with poop. It got “stuck” in our nasal passages and the smell would linger there for weeks.
We could smell a diaper and know the baby would be positive for “rota” before we even did the stool test. It was alarming how many babies were infected — hospital rooms would be doubled up, emergency rooms crammed, with more cases on the way. All of the infants needed IV fluids. As soon as we got one baby home, another quickly took that recovered baby’s place.
We saw the way it spread through families, day care centers and preschools and watched as parents missed multiple days of work.
Putting an IV in a small child is difficult and can be traumatic. Repeated vomiting would lead children to refuse to eat or drink, their little brains reacting as an unhelpful solution to their pain. We had confidence that most children would recover quickly, but it was scary for both parent and child.
The Decision
The U.S. Department of Health and Human Services did not provide a specific reason for why the rotavirus vaccine was removed from the list of vaccines it was recommending for all children. The goal was to reduce the number of vaccines given to children, but we do not see a logical basis for that approach. We are not sure why we would ever want to return to millions of infections each year.
Perhaps the change was rationalized by the fact that in a nation such as ours, where IV fluids are readily available, death from rotavirus is now very rare. Yet, children have died, and even one preventable death is unacceptable. Additionally, rotavirus vaccination has reduced hospitalizations and trauma for both babies and families, and lowered costs.
For that reason, pediatric health care providers still recommend rotavirus vaccination for all infants.
Except in very rare instances, the rotavirus vaccine is recommended as a safe and effective way to prevent hospitalization and death from rotavirus in children. The American Academy of Pediatrics and the American Academy of Family Medicine continue to strongly endorse universal vaccination.
Pia Fenimore, M.D., is a pediatrician at Lancaster Pediatric Associates and vice chair of pediatrics at Penn Medicine Lancaster General Health. Dr. Joan Thode, M.D., is a pediatrician at Penn Medicine Lancaster General Health Roseville Pediatrics. Both are fellows of the American Academy of Pediatrics.
