Everything you wanted to know about Rotavirus and its vaccine

What is rotavirus?

The rotavirus family includes at least 8 different groups (A to H), where A is the subgroup most commonly responsible for human infections. In addition, each group is further divided into subgroups based on the two main proteins (G and P) found on the viral capsule.
This is one of the reasons why recurrent infection, probably caused by different groups of the virus, is very common throughout life.

Who can get the virus and how?

Prior to the introduction of the vaccine, the rotavirus was the main cause of gastroenteritis (diarrhea) in young children. A large number of babies/children that would catch this virus for the first time would visit their primary care physician and many times be referred to the emergency room and end up in hospitalization, mostly due to dehydration.
The incubation period (the duration of time from infection to manifestation of symptoms of disease) is approximately 48 hours, during which large volumes of the virus can be found in the gastrointestinal system secretions. The virus is also found in stool several days after the resolution of symptoms and recovery.
Transmission from human to human is fecal-oral. That means, from one child’s stool, through surfaces and hands, to another child’s mouth. The virus can survive on surfaces for weeks.

What kind of disease does rota virus cause?

Usually, the presentation is typical – young child, in their first few years of life, that presents with vomiting first, and then 24-48 hours later, watery diarrhea. In about a third of the cases the disease is accompanied by high fever.
The duration of the illness is approximately 3-7 days, where the common complication is dehydration.
Older children, or adults, who get the infection for the second or third time present with a milder, such as diarrhea for 24 hours.
In children with immune suppression, or with past medical history, rotavirus infections can be very severe and require hospitalization, especially for hydration.
Unfortunately, I still remember the time when one child each year, mostly with extensive medical history, would pass away at our hospital due to complications caused by the virus, mostly dehydration, electrolyte imbalance and severe acidosis.

How is rotavirus diagnosed?

Back in the day we used to perform antigen testing in the stool.
Nowadays, in most hospitals and clinics, stool PCR testing, which is a more accurate test, is used.

How is rotavirus treated?

There is no specific treatment for rotavirus available.
The treatment is supportive and includes anti-pyretics for reducing fever (with an emphasis on paracetamol and not ibuprofen due to the risk of dehydration, as you will learn in the link here), hydration and treatment of electrolyte imbalances in children.
Mild cases manage with ORS at home (don’t know what ORS is? Here’s an important read in the following link) and more complex cases need to be treated with intravenous fluids in urgent care clinics.
In some of the cases we may see somewhat of an improvement in the child and then an additional worsening with more watery diarrhea. This typically indicates secondary lactase deficiency, which can sometimes happen in children with diarrhea. How should this be handled? The answer is in this link.

So, when a child has diarrhea, is it always caused by rotavirus?

Of course not. This was never true in the past, and it certainly isn’t true today (post-vaccine era). There are many more reasons and causes for diarrhea in children.
Let me remind you of the most important question you need to ask yourselves when your child has diarrhea, and that is whether the diarrhea is watery or mucousy/bloody.
What is the difference between watery diarrhea and mucousy or bloody diarrhea? Find the answer in this link.

When can a child go back to daycare or school after rotavirus infection?

As mentioned in the chapter about the return of children to school or daycare after an illness, you can send your child back about a day after their last episode of diarrhea.

What protects children from rotavirus?

Breastfeeding – since the mother transfers antibodies against pathogens that she tackled during her life, and because mothers will have antibodies against rotavirus, in breastfeeding infants the illness will usually be milder than in non-breastfeeding infants.
Vaccine – find out more about this below.

Is there a vaccine for rotavirus?

Yes. There are two types of vaccines for rotavirus.
Rota Teq – manufactured by Merck (MSD). Given in 3 doses as you will read below and contains 5 attenuated viral strains.
Rotarix – manufactured by GSK. Given in 2 doses and contains an attenuated viral strain.
In fact, two of these vaccines are live attenuated vaccines, given orally.
There is neither a benefit nor a disadvantage to either one of these vaccines, and the chosen vaccine in the different countries is mainly based on financial considerations rather than medical ones.

Since when has the rotavirus been a part of the routine vaccine schedules around the world?

In 2009, the WHO recommended implementing the rotavirus vaccines worldwide. Since then, the vaccines have been gradually introduced into the routine immunization schedules around the world.

When are the different doses of Rotateq vaccine given?

In most countries, the Rotateq doses are given at two, four and six months of age. The first dose can be given as early as 6 weeks of age but no later than 15 weeks (to those of you who remember too late). The minimum interval of time required between the different doses is 4 weeks. The series of vaccines must be completed before the child is 8 months old.

When are the different doses of Rotarix vaccine given?

In most countries the Rotarix, is given at ages two and four months. The first dose can be given as early as 6 weeks of age but no later than 15 weeks (to those of you who remember too late). The minimum interval of time required between the different doses is 4 weeks. The series of vaccines must be completed before the child is 8 months old.

How are the rotavirus vaccines administered?

The vaccine is administered through the mouth, using 2ml vials. The vials are opened, pressed on and the contents are squeezed into the child’s mouth. Even if the child spits up some of the liquid, an additional dose is not given, and the dose given is still counted.

How can we minimize the amount of vaccine that the child spits up?

If you squeeze the entire vial into the baby’s mouth (especially girls, I’ve noticed) in one go, the baby will probably immediately spit up the entire content out, and it’s a pity.
Therefore, make sure you have your baby in feeding position, place the vial inside the baby’s mouth and stimulate them so they suck on it slowly and swallow it. Do not try to squeeze the entire vial in one go down the middle of their throat. Instead, squeeze it slowly and gently, pointing it towards the inner cheek and pause in between squeezes, offer a soother and allow time for the baby to suck and swallow.
This will help prevent most of the content from being spurted out, and the child will be able to obtain better immunity.
Keep in mind that even if the child throws up or spits up the entire vial immediately after the vaccine has been administered, they will not receive another dose.

Can rotavirus vaccines be given together with other vaccines?

Of course. At two, four and six months of age, several other vaccines are given together with rotavirus.

Is splitting the vaccines and giving rotavirus separately recommended?

No. Why?
Keep it simple.

Who is not allowed to get the rotavirus vaccines?

There are several populations that should not receive the vaccine, including:
a. Children with fever. Allow the fever to resolve before vaccinating the child against rotavirus.
b. A severe reaction following a previous dose. Okay, this is obvious and applies to any vaccine or medication.
c. A known anaphylactic reaction to one of the components of the vaccine.
d. An immune deficiency – because this is a live attenuated vaccine, a child with immune deficiency should not receive the vaccine.
e. A child with a past medical history of intussusception. This is an interesting point because previously the guidelines talked about avoiding the vaccine in children with a congenital defect in the gastrointestinal system or those who had undergone surgical repair in their gastrointestinal system. Nonetheless, recently this was changed to children with a history of intussusception. In my opinion, if your child has a known congenital gastrointestinal defect, it is best to consult with their pediatrician about whether or not they should receive the vaccine.

What do the rotavirus vaccine adverse effects include?

If I believed everything I read on the internet, I would probably conclude that rotavirus is the greatest villain of all time. I think that because the timing of the vaccine is during the months in which the child undergoes lots of changes both in their nutrition and gastrointestinal tract, there is a tendency, especially in specific facebook groups, to relate the vaccine to many different adverse effects.
Among the true side effects are:
Diarrhea – approximately 1.3%
Vomiting – approximately 1.3%
Fever – up to 1%
Runny nose.
If you want to believe that the vaccine caused your child to have reflux, occult reflux, severe constipation, continuous diarrhea or anything else your imagination desires, I won’t argue with you.

What about intussusception and the rotavirus vaccine?

Intussusception is a type of obstruction in the small intestine in babies and children. There is a slight increase in the rates of intussusception in babies following the rotavirus vaccine. It has been seen in one in every 20-100 thousand doses of vaccines administered.
What are the signs of intussusception in children? Irritability, sharp pain and vomiting. In such situations I would suggest seeing a doctor, regardless of whether or not the child recently received a rotavirus vaccine.

What are the special instructions given to parents after the child has received the rotavirus vaccine?

All parents know that following rotavirus vaccine they need to make sure they take extra hygiene precautions when they change their child’s diaper. But this should apply to all the days of the year, and not only following rotavirus vaccine. So, I find it funny when parents are told to do this only after rotavirus vaccine.
Furthermore, even when there is a person who is immune deficient or pregnant residing in the same home as the child, there is no problem with administering the vaccine to your baby. Despite the fact that we know that the live attenuated virus is secreted in the stool of the vaccinated baby, there is no evidence that the virus can be transferred to a family member from this stool.

But Dr Efi, it is a mild childhood illness, everyone used to get it in the past. Why should we vaccinate our children? It is only diarrhea.

Again, one of the main issues with these vaccines is that people don’t remember anymore what it was like when their children actually had the illness that these vaccines prevent.
People do not vaccinate against polio, because they never saw how terrible polio is.
People do not vaccinate against measles, because we’ve been seeing less and less of it.
Same goes for rota. It is seemingly a milder illness than polio, but because all (and really all) of the children used to get rotavirus, the morbidity was so significant that at any given time there were always children with rotavirus hospitalized in different pediatric countries across the country.

Do those who get vaccinated not get infected?

The vaccine does not prevent infection but manifests in milder illness in those who get vaccinated and decreases the prevalence of severe illness and the need for hospitalization.
When I see children with rotavirus hospitalized nowadays (it is very uncommon but we do see it here and there), it is either an older child with significant past medical history or a younger child whose parents did not vaccinate him/her.

Do adults get infected with rotavirus?

As I mentioned in the beginning of this chapter, recurrent infection is common. Even though the first time you get the infection is usually the most significant.
However, there can be mild illness that manifests with abdominal pain and diarrhea, also in adults.

In summary, an unpleasant illness that I used to once encounter on a daily basis, and fortunately I now only encounter very rarely, because of the availability of a successful vaccine.