Vaccines for Preventing Rotavirus Diarrhoea: Vaccines in Use

Today marks the beginning of National Infection Control Week in Canada and the US. As part of the Child Health Emergency Medicine Social Media Campaign, we are highlighting a Cochrane summary on vaccines approved for the prevention of rotavirus diarrhoea. This review was selected for the TREKK Evidence Repository on intussusception.

Key Messages:

week-7-blogshot_intussusception_vaccines-for-rotavirus_v2

Related TREKK Resources:

Cochrane Summary:

Vaccines for preventing rotavirus diarrhoea: vaccines in use

Rotavirus infection is a common cause of diarrhoea in infants and young children, and can cause mild illness, hospitalization, and death. Rotavirus infections result in approximately half a million deaths per year in children aged under five years, mainly in low- and middle-income countries. Since 2009, the World Health Organization (WHO) has recommended that a rotavirus vaccine be included in all national immunization programmes.

This review evaluates a monovalent rotavirus vaccine (RV1; Rotarix, GlaxoSmithKline Biologicals) and a pentavalent rotavirus vaccine (RV5; RotaTeq, Merck & Co., Inc.). These vaccines have been evaluated in several large trials and are approved for use in many countries. No trials of the Lanzhou lamb rotavirus vaccine (LLR; Lanzhou Institute of Biomedical Products) were found; this vaccine is used in China only. The review includes 41 trials with 186,263 participants; all trials compared a rotavirus vaccine with placebo. The vaccines tested were RV1 (29 trials with 101,671 participants) and RV5 (12 trials with 84,592 participants). The trials took place in a number of worldwide locations.

In the first two years of life, RV1 prevented more than 80% of severe cases of rotavirus diarrhoea in low-mortality countries, and at least 40% of severe rotavirus diarrhoea in high-mortality countries. Severe cases of diarrhoea from all causes (such as any viral infection, bacterial infections, toxins, or allergies) were reduced after vaccination with RV1 by 35 to 40% in low-mortality countries, and 15 to 30% in high-mortality countries.

In the first two years of life, RV5 reduced severe cases of rotavirus diarrhoea by more than 80% in low-mortality countries, and by 40 to 57% in high-mortality countries. Severe cases of diarrhoea from all causes were reduced by 73% to 96% in low-mortality countries, and 15% in high-mortality countries, after vaccination with RV5. Diarrhoea is more common in high-mortality countries, so even modest relative effects prevent more episodes in this population. The vaccines when tested against placebo gave similar numbers of adverse events such as reactions to the vaccine, and other events that required discontinuation of the vaccination schedule.

Authors’ Conclusions:

RV1 and RV5 prevent episodes of rotavirus diarrhoea. The vaccine efficacy is lower in high-mortality countries; however, due to the higher burden of disease, the absolute benefit is higher in these settings. No increased risk of serious adverse events including intussusception was detected, but post-introduction surveillance studies are required to detect rare events associated with vaccination.

Check Out the Full Cochrane Systematic Review Below:

Soares-Weiser, K., Maclehose, H., Bergman, H., Ben-Aharon, I., Nagpal, S., Goldberg, E., Pitan, F., Cunliffe, N. (2012). Vaccines for preventing rotavirus diarrhoea: vaccines in use. Cochrane Database Syst Rev, 11, CD008521. doi: 10.1002/14651858.CD008521.pub3

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This post is part of a weekly blog series highlighting pediatric emergency medicine (PEM) focused Cochrane summaries and other key resources selected by TREKK.

Published by arrangement with John Wiley & Sons.

Treating Gastroenteritis: Evidence for Clinicians

April 13, 2015 – This week’s blog post is also available from TREKK (Translating Emergency Knowledge for Kids).

Fever. Vomiting. Diarrhea.

These are the symptoms that characterize one of the most common pediatric illnesses – Acute Gastroenteritis (AGE). In Canada, AGE accounts for 10% of emergency department visits annually and results in the hospitalization of 1 in 25 children under the age of five, keeping primary care physicians busy as ever (1,2). Although AGE is not a serious condition in the developed world, it exerts significant economic burden. Estimates suggest Canadian AGE specific costs are $3.7 billion annually (2).

Despite the prevalence of AGE, its cost, and the ubiquity of its symptomatic presentation, there is no unified approach to its management in emergency departments (ED) institutionally, nationally, or internationally. Standardized, clinical decision tools targeting improvement of gastroenteritis care are not routinely used in Canadian EDs, which can result in variation in clinical decisions for key treatment approaches (3). In effort to bring easily accessible, up-to-date evidence for AGE treatment approaches to one place, a Cochrane overview of systematic reviews provides a cohesive summary of treatment options and their effectiveness to help clinicians in their evidence-based decision making. This overview included four systematic reviews containing 95 randomized controlled trials involving over 12,000 participants. Here is the key evidence you need to know when treating a child with AGE.

Oral Rehydration Therapy (ORT) versus Intravenous (IV) Rehydration Therapy

  • ORT is less invasive than IV rehydration and therefore is considered as first line treatment for children with AGE and associated mild-to-moderate dehydration.
  • There are no important clinical differences (e.g. length of hospital stay, adverse effects) between children who receive oral rehydration therapy (ORT) and those administered IV rehydration therapy.

Anti-Emetics

  • Oral ondansetron is the first line anti-emetic agent for children with dehydration and significant vomiting because it lowers hospital admission and IV rehydration rates.
  • IV ondansetron is associated with lower hospital ED admission rates, but should only be used for children who require IV rehydration.

Probiotics

  • Probiotics can reduce hospital duration by over 24 hours.
  • There are no known interactions between probiotics and other medications.
  • Existing evidence favors the use of probiotics as a safe adjunct treatment for AGE, but it is unclear which probiotic should be used, at what dose, and for what duration.
  • Current evidence suggests the use of formulations containing Lactobacillus sp or boulardii, but optimal dosage and duration of therapy is unknown.

Dr. Moshe Ipp, a pediatrician and academic clinician from Toronto, shares his conclusions about this overview in this Cochrane Community podcast:

 “In summary, oral rehydration therapy is considered to be the first line choice for rehydration in patients with acute gastroenteritis and mild to moderate dehydration. When there is significant vomiting, ondansetron is the recommended anti-emetic of choice. And probiotics have been shown to be safe and effective for hospitalized children.”

However, Dr. Ipp highlights that ondansetron may not be suitable for all children with AGE: “An interesting finding, and a note of caution, is that in 3 randomized controlled trials there was a higher frequency of diarrhea in the ondansetron group compared to placebo, and because of this finding it is suggested that ondansetron might not be the agent of choice when vomiting is associated with a significant amount of diarrhea.” 

Attribution: Wikimedia Commons

Attribution: Wikimedia Commons

Resources:

TRanslating Emergency Knowledge for Kids (TREKK):

Cochrane Community Podcast:

  • Check out Dr. Ipp’s comments on the overview in this podcast

References: