Intussusception incidence among infants in the UK and Republic of Ireland: a pre-rotavirus vaccine prospective surveillance study

Unexpected Etiology of Intussusception in an Adolescent Patient

Intussusception is a common cause of acute and subacute small bowel obstruction in children, young, and older patients; however, despite increasing awareness of the condition and the number of patients diagnosed with it across all ages, its clinical and diagnostic approach remains challenging. A 17-year-old girl attended our gastroenterology outpatient department complaining of a 6-month history of recurrent right iliac fossa pain associated with nausea and vomiting at times with no past medical history of note. Initial blood tests revealed a slightly raised CRP (9.1 mg/L) and a significantly elevated fecal calprotectin (>1000 µg/g). Computed axial tomography scan of the abdomen and pelvis revealed ileocecal intussusception with no evidence of small or large bowel obstruction. On subsequent colonoscopy a 5-cm mass protruding through the ileocecal valve was identified and multiple biopsies were taken for histological analysis, which confirmed a diagnosis of Burkitt's lymphoma. The lesion was surgically resected and plans for adjuvant chemotherapy were discussed. The learning lessons to take from this case are to widen the list of differential diagnoses of unexplained recurrent abdominal pain to include intussusception and to actively rule it out with an appropriate diagnostic approach that addresses its potential malignant etiology across all ages.

Characteristics of intussusception among children in Hokkaido, Japan, during the pre- and post-rotavirus vaccine eras (2007-2016)

AIM

To analyse the epidemiology of intussusception in Hokkaido Prefecture, Japan during a 10-year period spanning the introduction of the rotavirus (RV) vaccine (2007-2016).

METHODS

Using a standard questionnaire, a retrospective surveillance was conducted across 17 hospitals with paediatric beds in Hokkaido Prefecture. We compared the data between the pre-vaccine era (2007-2011) and post-vaccine era (2012-2016).

RESULTS

In total, 208 and 110 intussusception cases were in the pre- and post-vaccine eras, respectively. A significant reduction of the intussusception incidence in children aged <1 year was observed from the pre- to the post-vaccine era (102.4-56.5 per 100 000 infants; incidence rate ratio, 0.55; p = 0.004). There was a relatively high-positive RV antigen detection rate (29.4%, 5/17) during the RV epidemic period in Japan (March-May) in the pre-vaccine era. None of the intussusception cases in the 31 patients with a history of RV vaccination occurred within 1 month after the administration of an RV vaccine dose.

CONCLUSIONS

The incidence of intussusception in children aged <1 year decreased significantly after RV vaccine introduction in Japan. Another survey is needed to determine how the incidence of intussusception has changed further since the introduction of routine RV vaccination in 2020.

Current diagnosis and image-guided reduction for intussusception in children

Intussusception involves an invagination of the proximal bowel into the distal bowel, with ileocolic intussusception being the most common type. However, a diagnostic delay can lead to intestinal ischemia, bowel infarction, or even death; therefore, its early diagnosis and management are important. The primary role of abdominal radiography is to detect pneumoperitoneum or high-grade bowel obstruction in cases of suspected intussusception, and ultrasonography is the modality of choice for its diagnosis. Nonoperative enema reduction, the treatment of choice for childhood intussusception in cases without signs of perforation or peritonitis, can be safely performed with a success rate of 82%. Enema reduction can be performed in various ways according to image guidance method (fluoroscopy or ultrasonography) and reduction medium (liquid or air). Successful enema reduction is less likely to be achieved in children with a longer symptom duration, younger age, lethargy, fever, bloody diarrhea, unfavorable radiologic findings (small bowel obstruction, trapped fluid, ascites, absence of flow in the intussusception, intussusception in the left-sided colon), and pathological lead points. This review highlights the current concepts of intussusception diagnosis, nonsurgical enema reduction, success rates, predictors of failed enema reduction, complications, and recurrence to guide general pediatricians in the management of childhood intussusception.

Intussusception and COVID-19 in Children: A Systematic Review and Meta-Analysis

Background: Intussusception (ISN) post-COVID-19 infection in children is rare but can occur. SARS-CoV-2 may play a role in the pathogenesis of ISN and trigger immune activation and mesenteric adenitis, which predispose peristaltic activity to “telescope” a proximal bowel segment into the distal bowel lumen. Objectives: To estimate the prevalence of SARS-CoV-2 infection in ISN children and analyze the demographic parameters, clinical characteristics and treatment outcomes in ISN pediatric patients with COVID-19 illness. Methods: We performed this systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Studies reporting on the incidence of ISN post-SARS-CoV-2 infection in children, published from 1 December 2019 until 1 October 2022, in PROQUEST, MEDLINE, EMBASE, PUBMED, CINAHL, WILEY ONLINE LIBRARY, SCOPUS and NATURE, with a restriction to articles available in the English language, were included. Results: Of the 169 papers that were identified, 34 articles were included in the systematic review and meta-analysis (28 case report, 5 cohort and 1 case-series studies). Studies involving 64 ISN patients with confirmed COVID-19 (all patients were children) were analyzed. The overall pooled proportions of the ISN patients who had PCR-confirmed SARS-CoV-2 infection was 0.06% (95% CI 0.03 to 0.09, n = 1790, four studies, I2 0%, p = 0.64), while 0.07% (95% CI 0.03 to 0.12, n = 1552, three studies, I2 0%, p = 0.47) had success to ISN pneumatic, hydrostatic and surgical reduction treatment and 0.04% (95% CI 0.00 to 0.09, n = 923, two studies, I2 0%, p = 0.97) had failure to ISN pneumatic, hydrostatic and surgical reduction treatment. The median patient age ranged from 1 to 132 months across studies, and most of the patients were in the 1−12 month age group (n = 32, 50%), p = 0.001. The majority of the patients were male (n = 41, 64.1%, p = 0.000) and belonged to White (Caucasian) (n = 25, 39.1%), Hispanic (n = 13, 20.3%) and Asian (n = 5, 7.8%) ethnicity, p = 0.000. The reported ISN classifications by location were mostly ileocolic (n = 35, 54.7%), and few children experienced ileo-ileal ISN (n = 4, 6.2%), p = 0.001. The most common symptoms from ISN were vomiting (n = 36, 56.2%), abdominal pain (n = 29, 45.3%), red currant jelly stools (n = 25, 39.1%) and blood in stool (n = 15, 23.4%). Half of the patients never had any medical comorbidities (n = 32, 50%), p = 0.036. The approaches and treatments commonly used to manage ISN included surgical reduction of the ISN (n = 17, 26.6%), pneumatic reduction of the ISN (n = 13, 20.2%), antibiotics (n = 12, 18.7%), hydrostatic reduction of the ISN (n = 11, 17.2%), laparotomy (n = 10, 15.6%), intravenous fluids (n = 8, 12.5%) and surgical resection (n = 5, 7.8%), p = 0.051. ISN was recurrent in two cases only (n = 2, 3.1%). The patients experienced failure to pneumatic (n = 7, 10.9%), hydrostatic (n = 6, 9.4%) and surgical (n = 1, 1.5%) ISN treatment, p = 0.002. The odds ratios of death were significantly higher in patients with a female gender (OR 1.13, 95% CI 0.31−0.79, p = 0.045), Asian ethnicity (OR 0.38, 95% CI 0.28−0.48, p < 0.001), failure to pneumatic or surgical ISN reduction treatment (OR 0.11, 95% CI 0.05−0.21, p = 0.036), admission to ICU (OR 0.71, 95% CI 0.83−1.18, p = 0.03), intubation and placement of mechanical ventilation (OR 0.68, 95% CI 0.51−1.41, p = 0.01) or suffering from ARDS (OR 0.88, 95% CI 0.93−1.88, p = 0.01) compared to those who survived. Conclusion: Children with SARS-CoV-2 infection are at low risk to develop ISN. A female gender, Asian ethnicity, failure to ISN reduction treatment (pneumatic or surgical), admission to ICU, mechanical ventilation and suffering from ARDS were significantly associated with death following ISN in pediatric COVID-19 patients.

Ultrasound Findings to Predict Risk of Recurrence in Pediatric Intussusception After Air Enema Reduction

OBJECTIVES

Intussusception is one of the most common abdominal emergencies in early children. Intussusception recurs in 8-20% of children after successful nonoperative reduction. The aim of this study was to explore the ultrasound findings to predict risk of recurrence in pediatric intussusception after air enema reduction.

METHODS

A total of 336 intussusception children were followed up for 1 year after received successful air enema reduction. They were divided into the recurrent group and the non-recurrent group. The differences of clinical characteristics, ultrasonic features, and laboratory tests were analyzed by univariate analyses and the Cox proportional hazard model.

RESULTS

Sixty-five children with recurrent intussusception were identified. There were statistically significances in the diameter of the mass, in the presence or absence of enlarged lymph nodes out of the sleeve, and in the sleeve between recurrent and non-recurrent groups (P < .05). Other ultrasonic features, clinical characteristics, and blood parameters had no differences (P > .05). Multivariate Cox proportional hazard model showed that the diameter of the mass and abdominal lymph nodes may be the risk factors of intussusception recurrence (HR = 1.395, 95% CI: 1.045~1.863 and HR = 2.078, 95% CI: 1.118~3.865, P < .05). The cut-off value of mass diameter was 2.55 cm, above which recurrence is more likely.

CONCLUSIONS

Intussusception recurrence was prone with greater mass diameter (>2.55 cm) and enlarged abdominal lymph nodes. Although these ultrasound findings for recurrence do not necessarily reduce the rate of recurrence, it can predict the recurrent possibility, and help the emergency physicians to be more vigilant in these children and better counsel parents upon discharge.

Review of Over 15 Years Postmarketing Safety Surveillance Spontaneous Data for the Human Rotavirus Vaccine (Rotarix) on Intussusception

Introduction

Rotavirus (RV) is the most common cause of acute gastroenteritis in children <5 years of age worldwide, and vaccination reduces the disease burden. Evidence from postmarketing surveillance studies suggested an increased risk of intussusception (IS) in infants post-RV vaccination. An overall positive benefit–risk balance for the human RV vaccine (HRV) Rotarix (GlaxoSmithKline [GSK], Belgium) has been established and recent findings indicate an indirect effect of reduced IS over the long term.

Objective

The aim of this study was to discuss spontaneous data from the GSK worldwide safety database on IS post-Rotarix administration.

Methods

The database was reviewed for all spontaneous IS cases from 2004 to 2020. Additionally, an observed versus expected (O/E) analysis was done for adverse events attributed to IS. Data were reviewed as overall worldwide and stratified by region (Europe/USA/Japan) and dose.

Results

A male predominance of IS patients was observed, consistent with earlier reports. The most frequently reported events in confirmed IS cases (Brighton Collaboration Working Group [BCWG] level 1) with time to onset ≤ 30 days post-vaccination were vomiting (55.8%), haematochezia (47.2%), and crying (21.1%). The observations from the IS spontaneous cases review and results of the O/E analysis are consistent with the known IS safety profile of RV vaccines: a transient increased incidence of IS post-vaccination (primarily in Europe/Japan/worldwide), mostly within 7 days postdose 1.

Conclusion

Since the outcomes of early IS management are favourable over delayed management, healthcare professionals should inform parents about the importance of seeking immediate medical advice in case of unusual behaviour of the vaccinated infant. GSK continues to monitor the IS risk post-Rotarix administration through routine pharmacovigilance activities.

Graphic abstract

Supplementary Information

The online version contains supplementary material available at 10.1007/s40264-021-01141-4.

Rotavirus (RV) is the most common cause of acute gastroenteritis and a major cause of death in young children worldwide. Vaccination has been instrumental in reducing the impact of RV disease. Real-world evidence suggests an increased risk of intussusception (an infrequent type of bowel obstruction) in infants following RV vaccination. We reviewed IS cases reported spontaneously worldwide in children following a two-dose vaccination with the human RV vaccine (Rotarix, GlaxoSmithKline [GSK]) since its launch in 2004. We observed that (1) IS occurred more frequently 7 days after the first dose and, to a lesser extent, after the second dose; (2) boys were more frequently affected than girls (56.3%); (3) of 862 confirmed reported cases, 557 required hospitalisation; and (4) surgical intervention was required for 294 of 557 hospitalised cases. We used statistical analysis to assess whether the number of cases observed would be higher or lower than the natural occurrence of IS (irrespective of vaccination). These results were in line with the known RV vaccine safety profile. It is important to constantly monitor the real-world safety profile of RV vaccines in the postmarketing setting. Since the outcomes of early management of IS are favourable compared with delayed management, healthcare professionals should inform parents to seek immediate medical advice if they observe unusual behaviour in their vaccinated child. In conclusion, our analyses on data of a large patient pool for this rare event reinforce the favourable safety profile of human RV vaccine and the benefits of vaccination in young children.

Epidemiology of intussusception among infants in Togo, 2015-2018

Introduction

intussusception is the leading cause of bowel obstruction in infants and young children. We describe the epidemiology and diagnostic and treatment characteristics of intussusception among Togolese infants over a 4-year period.

Methods

we implemented active surveillance among infants younger than 1 year of age admitted with intussusception from 2015 to 2018 at Sylvanus Olympio Teaching Hospital and in 2018 at Campus Teaching Hospital. Brighton Collaboration Level 1 case definition criteria were used to confirm the diagnosis of intussusception.

Results

during four years, 41 cases of intussusception, with an annual range of 8 to 14 cases (median: 10) were reported; and the highest number of cases (89%) was enrolled at Sylvanus Olympio teaching hospital. Intussusception was uncommon in the first 2 months of life, peaked from 5 to 7 months old (63%), with male predominance (63%), and showed no significant seasonality. One third of cases (34%) were transferred to the sentinel surveillance site from another health facility; and the median delay in seeking care was 4 days (range: 0-11) with ≥ 48-hour delay in 59% of cases. Clinical symptoms, ultrasound and surgery were combined to diagnose intussusception in all the cases (100%). The treatment was exclusively surgical, and intestinal resection was common (28/41, 68%). A high case fatality rate (23%) was observed and the average length of hospital stay was 10 days (range: 1-23).

Conclusion

active surveillance for intussusception in Togo has highlighted exclusive use of surgical therapy; often associated to an intestinal resection with a very high case fatality rate.

Delays in presentation of intussusception and development of gangrene in Zimbabwe

Introduction

prompt diagnosis and treatment are considered key to successful management of intussusception. We examined pre-treatment delay among intussusception cases in Zimbabwe and conducted an exploratory analysis of factors associated with intraoperative finding of gangrene.

Methods

data were prospectively collected as part of the African Intussusception Network using a questionnaire administered on consecutive patients with intussusception managed at Harare Children´s Hospital. Delays were classified using the Three-Delays-Model: care-seeking delay (time from onset of symptoms to first presentation for health care), health-system delay (referral time from presentation to first facility to treatment facility) and treatment delay (time from presentation at treatment facility to treatment).

Results

ninety-two patients were enrolled from August 2014 to December 2016. The mean care-seeking interval was 1.9 days, the mean health-system interval was 1.5 days, and the mean treatment interval was 1.1 days. Mean total time from symptom onset to treatment was 4.4 days. Being transferred from another institution added 1.4 days to the patient journey. Gangrene was found in 2 (25%) of children who received treatment within 1 day, 13 (41%) of children who received treatment 2-3 days, and 26 (50%) of children who received treatment more than 3 days after symptom onset (p = 0.34).

Conclusion

significant care-seeking and health-system delays are encountered by intussusception patients in Zimbabwe. Our findings highlight the need to explore approaches to improve the early diagnosis of intussusception and prompt referral of patients for treatment.

Association of air temperature with pediatric intussusception in northeastern China: A 10-year retrospective study

OBJECTIVE

The aim of this study was to determine whether an association existed between intussusception and air temperature.

METHODS

A retrospective study was performed between March 2006 and February 2016 to determine the relationship between pediatric primary intussusception (PPI) and air temperature. Information from hospital records of 5922 cases of PPI and Mean daily temperatures of Shenyang were obtained. Pearson correlation analysis was used to examine the association between monthly PPI cases and monthly mean temperature. Factorial analysis-of-variance was used to examine differences in the numbers of seasonal PPI cases during different seasons.

RESULTS

Monthly PPI cases fluctuated throughout the year, with a peak in June, and a trough in February. Pearson correlation analysis showed that monthly PPI cases was associated with the monthly mean temperature (p < 0.01). Factorial analysis-of-variance showed there was significant difference in the numbers of seasonal PPI cases during different seasons. Multiple comparison showed a significant difference in seasonal PPI cases between spring and summer, spring and winter, summer and autumn, summer and winter, autumn and winter (p < 0.01).

CONCLUSIONS

Monthly PPI cases were positively associated with monthly mean temperature in Shenyang. The incidence of intussusception shows a seasonal trend, with a peak in summer (May to July).

Nationwide Population-Based Epidemiologic Study on Childhood Intussusception in South Korea: Emphasis on Treatment and Outcomes

PURPOSE

This was a nationwide population-based study conducted to investigate the epidemiology, treatment, disease outcomes, and associated factors of childhood intussusception in South Korea.

METHODS

Data from the Korean National Health Insurance Service database on all patients <18 years old diagnosed with intussusception from 2007 to 2017 were analyzed.

RESULTS

A total of 34,688 cases were identified among 30,444 patients. The overall incidence was 28.3/100,000 person-years with a male predominance. Most cases (83.1%) occurred in children <3 years old, with an annual incidence of 195.2, 200.1, and 118.6 cases per 100,000 children in their first, second, and third year of life, respectively. The median age at the first occurrence was 18.7 months, and it was higher in boys than in girls. The post-discharge recurrence rate was 10.6% (3,226/30,444) and the in-hospital recurrence rate was 6.1% (1,842/30,444). The total recurrence rate (post-discharge recurrence and/or in-hospital recurrence) was 15.0% (4,580/30,444). Enema reduction was successful in 90.0% of cases. Enema reduction was more successful in girls than in boys. A total of 3,296 (10.8%) patients underwent 3,481 surgeries, including 735 (21.1%) laparoscopic surgeries. Post-discharge recurrence and surgery were significantly affected by age, sex, and hospital type. Mortality was noted in nine cases (0.03%).

CONCLUSION

Our study provides accurate epidemiologic data on the treatment and outcomes of intussusception through complete enumeration during an 11-year-period.

Update on the global epidemiology of intussusception: a systematic review of incidence rates, age distributions and case-fatality ratios among children aged <5 years, before the introduction of rotavirus vaccination

Background

In some countries that have introduced oral rotavirus vaccines, a small but elevated risk of intussusception—a rare bowel disorder—has been reported. Updated estimates on the global epidemiology of intussusception are needed to help predict the potential number of intussusception cases that could be caused by the vaccine in different settings.

Methods

We estimated incidence rates, age distributions and case-fatality ratios (CFRs) for intussusception hospital admissions among children aged <5 years, before the introduction of rotavirus vaccines. We included all articles identified in a systematic review between January 2002 and January 2018, and contacted authors for more granular unpublished data on age distributions.

Results

We identified 128 articles containing 227 country datasets (61 age distributions, 71 incidence rates and 95 CFRs). The median age of intussusception ranged from 29 weeks in Africa (83% of cases in the first year of life) to 70 weeks in the Western Pacific region (35% of cases in the first year of life). The median (range) annual incidence of intussusception hospital admissions per 100 000 aged <1 year ranged from 34 (13–56) in Africa to 90 (9–380) in the Western Pacific region. We found extreme differences between the CFRs in Africa (1 death in every 10 hospital admissions) and the rest of the world (fewer than 1 death in every 100–2000 hospital admissions).

Conclusion

Intussusception epidemiology varies by country and region. Understanding and recognizing these differences will be important when assessing the potential number of intussusception cases associated with rotavirus vaccines.

Intussusception among Norwegian children: What to expect after introduction of rotavirus vaccination?

BACKGROUND

To reduce the risk of vaccine-associated intussusception, rotavirus vaccination in Norway was implemented under strict age limits (the first dose given by 12 weeks of age and the second dose by 16 weeks of age) in 2014. We estimated the incidence of intussusception in children <2 years old before vaccine introduction and the number of vaccine-associated cases under current and extended age limits for vaccine administration in Norway.

METHODS

To estimate the baseline incidence, we validated all diagnoses in children <2 years old registered in the national hospital registry during the pre-vaccine period of 2008-2013. Using national vaccine coverage data and international estimates of intussusception risk after rotavirus vaccination, we calculated the numbers of expected vaccine-associated intussusception cases to compare with the estimated numbers of averted rotavirus cases. Uncertainty was accounted for by several scenario analyses using current and extended age limits for vaccine administration.

RESULTS

The pre-vaccine incidence of intussusception was 26.7 (95% CI 23.1-30.6) cases/year per 100,000 children <2 years old and 37.1 (95% CI 31.2-43.8) cases/year per 100,000 children <1 year old. In the 2016 birth cohort (approx. 60,000) vaccinated under the current age limits, 1.3 (95% CI 0.7-2.0) vaccine-associated intussusception cases were expected to occur. If age limits were extended to 16 weeks for the first vaccine dose and 24 weeks for the second dose, leading to more children vaccinated at an older age, 2.2 (95% CI 1.2-3.5) excess cases would be expected in the same cohort. Simultaneously, an estimated 1768 rotavirus hospitalizations/year in children <5 years old would be averted under current age limits, with 98 additional rotavirus hospitalizations averted under extended age limits.

CONCLUSIONS

Administering rotavirus vaccines beyond current age limits in Norway would lead to a marginal increase in the number of intussusception cases, which would be offset by the benefits of vaccination.

A case-control study of risk factors for intussusception among infants in eastern France after the introduction of the rotavirus vaccine

OBJECTIVE

The objective of the present study was to investigate the risk factors for intussusception (IS) among infants, including vaccination against rotavirus.

METHODS

Case-control study with systematic inclusion of all infants aged <1 year with suspected IS admitted to emergency departments in the eastern region of France between 1 April 2008 and 31 March 2012. All cases classed level 1 according to the Brighton classification were matched to 4 hospital controls. Two exposure windows were examined; exposure to the first dose of rotavirus vaccine in the 7 and in the 14 days prior to the occurrence of IS.

RESULTS

A total of 115 cases were matched with 457 controls. The average vaccination coverage rate over the 4 years of study was 8.6%. Rotavirus vaccine was not found to be significantly associated with the occurrence of IS in the 7 days (odds ratio (OR) not calculated; p = 0.99) and in the 14 days after administration of one dose vaccine (OR 1.33, 95% confidence interval (CI) 0.14-12.82). Infant formula alone or combined with breastfeeding was associated with an excess risk of IS (OR 2.74, 95% CI 1.10-6.79). A history of gastroenteritis within 2 weeks prior to hospitalisation was also associated with an increased risk (OR 2.24, 95% CI 1.07-4.67).

CONCLUSION

Our study indicates that infant formula alone or combined with breastfeeding is a risk factor for IS. A small, non-significant increase in the risk of IS was observed after rotavirus vaccination, although the low vaccine coverage rate likely precluded detection of a significant increase in risk.

Rotavirus: Genetics, pathogenesis and vaccine advances

Since its discovery 40 years ago, rotavirus (RV) is considered to be a major cause of infant and childhood morbidity and mortality particularly in developing countries. Nearly every child in the world under 5 years of age is at the risk of RV infection. It is estimated that 90% of RV-associated mortalities occur in developing countries of Africa and Asia. Two live oral vaccines, RotaTeq (RV5, Merck) and Rotarix (RV1, GlaxoSmithKline) have been successfully deployed to scale down the disease burden in Europe and America, but they are less effective in Africa and Asia. In April 2009, the World Health Organization recommended the inclusion of RV vaccination in national immunization programs of all countries with great emphasis in developing countries. To date, 86 countries have included RV vaccines into their national immunization programs including 41 Global Alliance for Vaccines and Immunization eligible countries. The predominant RV genotypes circulating all over the world are G1P[8], G2P[4], G3P[8], G4P[8], and G9P[8], while G12[P6] and G12[P8] are emerging genotypes. On account of the segmented genome, RV shows an enormous genetic diversity that leads to the evolution of new genotypes that can influence the efficacy of current vaccines. The current need is for a global RV surveillance program to monitor the prevalence and antigenic variability of new genotypes to formulate future vaccine development planning. In this review, we will summarize the previous and recent insights into RV structure, classification, and epidemiology and current status of RV vaccination around the globe and will also cover the status of RV research and vaccine policy in Pakistan.

Intussusception Rate Among Under-Five-Children Before Introduction of Rotavirus Vaccine in North India

BACKGROUND

Baseline data on intussusception are needed to compare the intussusception rates following introduction of rotavirus vaccine.

METHODS

A hospital-based bidirectional surveillance (retrospective from 2009 to 2012; and prospective from 2013 to 2015) was set up in a tertiary care hospital in Chandigarh, India, to enrol children <5 years of age admitted with intussusception as per Brighton's classification, to estimate the hospital admission rate. Incidence of intussusception among infants and children <5 years of age was also estimated.

RESULTS

A total of 277 intussusception cases (96 retrospective; 181 prospective) were reported. Majority of cases were males (69.7%) and infants (72%). Median age at diagnosis was 10 months (interquartile range 6-12 months). Nearly 62% cases were treated surgically and 33% radiologically. Incidence was estimated to be 20/100 000 infants, and 5/100 000 children <5 years of age per year, in Chandigarh.

CONCLUSION

Intussusception surveillance system provided background hospital admission and incidence rate before rotavirus vaccine introduction in North India.

Incidence and epidemiology of intussusception among children under 2 years of age in Chenzhou and Kaifeng, China, 2009-2013

INTRODUCTION

In China, rotavirus is the leading cause of diarrhea hospitalizations among children aged <5 years. A locally manufactured rotavirus vaccine is available for private market use, but little is known about its coverage. Given the impending availability of newer rotavirus vaccines, we evaluated intussusception rates among children aged <2 years to better understand intussusception epidemiology for future vaccine safety monitoring.

METHODS

We conducted a retrospective review at 4 hospitals in Chenzhou City of Hunan Province and Kaifeng City of Henan Province. We identified intussusception cases admitted during 2009-2013 by reviewing medical records with the ICD-10 discharge code for intussusception and extracting demographic and clinical information from the electronic clinical record systems.

RESULTS

During 2009-2013, 1715 intussusception hospitalizations among 1,487,215 children aged <2 years occurred in both cities. The average annual intussusception hospitalization incidence was 112.9 per 100,000 children aged <2 years (181.8 per 100,000 children <1 year; 56 per 100,000 children 1 to <2 years). Intussusception incidence was low among infants aged <3 months and peaked at age 6-8 months. No clear seasonality was observed. Ultrasound was used to diagnose 95.9% of cases. Enema reduction was performed in 80% cases; 25% of cases in Chenzhou and 16% in Kaifeng required surgical intervention. No deaths were reported. The median time between symptom onset and admission was 1 day.

CONCLUSIONS

This study provides information on intussusception incidence and epidemiology in two cities of China during 2009-2013. Monitoring intussusception rates in this population will be important in the post-rotavirus vaccine era.

Baseline incidence of intussusception in early childhood before rotavirus vaccine introduction, the Netherlands, January 2008 to December 2012

Intussusception is a rare, potentially life-threatening condition in early childhood. It gained attention due to an unexpected association with the first rotavirus vaccine, RotaShield, which was subsequently withdrawn from the market. Across Europe, broad variations in intussusception incidence rates have been reported. This study provides a first estimate of intussusception incidence in young children in the Netherlands from 1 January 2008 to 31 December 2012, which could be used for future rotavirus safety monitoring. Our estimates are based on two different sources: electronic medical records from the primary healthcare database (IPCI), as well as administrative data from the Dutch hospital register (LBZ). The results from our study indicate a low rate of intussusception. Overall incidence rate in children < 36 months of age was 21.2 per 100,000 person-years (95% confidence interval (CI): 12.5–34.3) based on primary healthcare data and 22.6 per 100,000 person-years (95% CI: 20.9–24.4) based on hospital administrative data. The estimates suggest the upper and lower bound of the expected number of cases.

Preparing for rotavirus vaccine introduction - A retrospective assessment of the epidemiology of intussusception in children below 2 years of age in Nepal

BACKGROUND

Rotavirus is the most common cause of severe diarrhea in Nepali children, accounting for 25-33% of childhood diarrhea hospitalizations. Two rotavirus vaccines recommended for inclusion in national immunization programs have been associated with a low risk of intussusception in post-marketing studies conducted in several countries. Data on the epidemiology of intussusception hospitalizations are lacking in Nepal. Thus, we aimed to describe the epidemiology of intussusception-associated hospitalizations among Nepali children in preparation for rotavirus vaccine introduction.

METHODS

A retrospective review of intussusception hospitalizations for a three year period was conducted at two major pediatric hospitals in Kathmandu, Nepal. Possible intussusception cases were identified through admission, discharge, and operation theater logs and ultrasound registers. Cases with a diagnosis of possible intussusception were selected for medical record review and classified as confirmed if they met the Brighton Collaboration level 1 criteria of diagnostic certainty and the child was aged < 24 months. Data on demographics, clinical course, and outcome were abstracted and analyzed.

RESULTS

Eight-five confirmed intussusception cases were identified; most (96%) were confirmed at surgery. The number of intussusception cases peaked between ages 4-7 months; no cases occurred in children 0-2 months. Fifty-nine (64%) case-patients were male. The median duration of symptoms before admission was 2 days (range: 0-14). Abdominal pain, bloody stool, and vomiting were the most common clinical features. All cases underwent surgical treatment; there was only one death.

CONCLUSIONS

This is the first study to evaluate the epidemiology of intussusception hospitalizations among children aged < 24 months in Nepal. Because the public health impact of rotavirus vaccination could be substantial in Nepal, where childhood diarrhea-related morbidity and mortality are high, this baseline knowledge of intussusception prior to introduction of rotavirus vaccine in the national immunization schedule will provide useful information for post-vaccine introduction safety monitoring.

Intussusception-related Hospitalizations Among Infants Before and After Private Market Licensure of Rotavirus Vaccines in Taiwan, 2001-2013

INTRODUCTION

Rotavirus is a leading cause of acute gastroenteritis among Taiwanese children. Two globally licensed rotavirus vaccines recommended for inclusion in routine immunization programs that have been available for private market use in Taiwan since 2006 have been associated with a low risk of intussusception in postmarketing studies conducted in several countries. Our objective was to examine trends and characteristics of intussusception hospitalizations in Taiwan among children <12 months of age before and after rotavirus vaccine licensure to provide updated baseline and early postlicensure data.

METHODS

We extracted data on intussusception-related hospitalizations among children <12 months of age during 2001-2013 from the National Health Insurance Research Database. We examined patient demographics, clinical outcome and hospitalization trends, focusing on recommended ages for rotavirus vaccination (6-14, 15-24 and 25-34 weeks). We compared mean hospitalization rates for prevaccine licensure years 2001-2005 with those for postvaccine licensure years 2007-2013 using Poisson regression analysis.

RESULTS

During 2001-2013, 1998 intussusceptions hospitalizations were recorded. The mean age of hospitalization was 33 weeks. Almost all children recovered; 3 deaths occurred. The overall intussusception hospitalization rate was 75.1 per 100,000; seasonality was not evident. Hospitalization rates were greatest in children ≥25 weeks of age and occurred more frequently in boys. Prevaccine and postvaccine licensure trends in annual hospitalization rates did not significantly differ. However, mean hospitalization rates were lower during the postvaccine licensure period for children <12 months of age (rate ratio: 0.84, 95% confidence interval: 0.76-0.92) with the greatest decline among children 25-34 weeks of age (rate ratio: 0.66, 95% confidence interval: 0.55-0.78).

CONCLUSIONS

Infant intussusception in Taiwan occurs at a rate within the range of other Asian countries is rare among children <3 months of age, has a male predominance and does not have a clear seasonality pattern. We did not observe a postlicensure increase in intussusception hospitalization rates in children 6-14 weeks of age.

Epidemiology of childhood intussusception in Bangladesh: Findings from an active national hospital based surveillance system, 2012-2016

INTRODUCTION

Rotavirus vaccines have significantly decreased the burden of diarrheal diseases in countries that have introduced them into their immunization programs. In some studies, there has been a small association between rotavirus vaccines and intussusception in post-marketing surveillance, highlighting the importance of tracking incidence before and after vaccine introduction. The objective of this study was to describe the epidemiology of intussusception among Bangladeshi children pre-vaccine introduction.

METHODS

We conducted active, hospital-based surveillance for intussusception at 7 tertiary care hospitals with pediatric surgical facilities during July 2012 to September 2016. Hospitalized children under 2years of age were identified according to Brighton Collaboration level 1 criteria for intussusception. The frequency and proportion of intussusception among overall surgical admissions, as well as the demographic and clinical information of the cases is described.

RESULTS

Overall 153 cases of intussusception among children <2years-old were identified at participating sites over the enrolment period, confirmed by Level 1 Brighton criteria. These cases represented 2% of all surgical admissions under 2years of age. One hundred twelve cases (73%) were male; the median age was 7months; and the median duration of hospitalization was 7days. One hundred forty-six (95%) children with intussusception required surgery, and 11 (7%) died.

CONCLUSIONS

Confirmed cases of intussusception represented nearly 2% of pediatric surgical admissions at tertiary referral centers in Bangladesh during the study period and 7% of children with intussusception died. Given the high burden of rotavirus disease in Bangladesh, vaccine introduction is warranted, however, further studies after introduction of rotavirus vaccine are necessary to determine any association between vaccine and intussusception in this setting.

Assessing the risk of intussusception and rotavirus vaccine safety in Canada

BACKGROUND

Intussusception has been identified as a rare adverse event following rotavirus immunization. We sought to determine the incidence of intussusception among infants in Canada both before and after introduction of rotavirus immunization programs.

METHODS

We used Canadian Institute for Health Information (CIHI) Discharge Abstract Database (DAD) to identify infants under 1 y of age who were admitted to a Canadian hospital, which the exception of Quebec, which does not submit data to CIHI, with a diagnosis of intussusception (ICD-10 code K56.1, and ICD-9 code 560) between January 1st, 2003 and December 31, 2013. We compared rates of intussusception hospitalization before and after rotavirus vaccine program introduction. Rates were adjusted for calendar year, age (in months), sex and region using Poisson regression models. Denominator data for infants under 1 year, stratified by age in months, were obtained from Statistics Canada.

RESULTS

Annual intussusception hospitalization rates ranged from 20-30 per 100,000 infants over the study period, with no evidence of a trend over time. Intussusception hospitalization rates were highest in infants 4 to <8 months and lowest in those under 2 months or between 10 and <12 months. Males had higher rates than females both overall and within each age group. The rate of intussusception hospitalization after rotavirus vaccine program introduction was 22.4 (95% CI: 18.3, 27.4) compared to 23.4 (95% CI: 21.5, 25.4) per 100,000 before program introduction.

CONCLUSIONS

We have described baseline intussusception hospitalization rates for infants in Canada and have found no evidence of a change in rate after implementation of routine rotavirus immunization programs.

Incidence of acute intussusception among infants in eastern France: results of the EPIstudy trial

The incidence of intussusception in infants varies around the world. The epidemiology of intussusception in France has never been prospectively studied. We performed a prospective observational study with systematic inclusion of all infants aged <1 year with suspected intussusception admitted to the emergency departments of the hospitals in the eastern region of France (98,000 live births per year), from 4/1/2008 to 3/31/2012. Cases were classified using the Brighton Collaboration classification. In total, 185 infants with suspected intussusception were included of which 169 were idiopathic intussusception. Among these 169 cases, 115 (68%) were classed as Brighton level 1 (confirmed cases). Overall incidence of intussusception over the 4 years of the study was 29.8 (95% CI 24.6-35.7) cases per 100,000 live births for level 1 and 37.5 (95% CI 31.7-44.2) cases per 100,000 live births for all cases (levels 1-4). Annual incidence rates of level 1 intussusception were as follows: 44 (95% CI 31.9-59.3), 30.9 (20.9-44.2), 21.7 (13.4-33.2) and 22.1 (13.7-33.8) per 100,000 live births in the 1st, 2nd, 3rd and 4th study years, respectively.

CONCLUSION

The incidence rate of intussusception in the eastern part of France is comparable to that of other European countries. There was a significant trend towards a decrease in the incidence of intussusception. What is known • Intussusception is the most frequent causes of intestinal obstruction in infants and young children. Overall incidence of intussusception in infants aged <1 year varies widely around the world. No specific epidemiological studies have not been conducted in France on intussusception. What is new: • This prospective and multicenter study provides important information about the epidemiology of intussusception in infants in France over a period of 4 years.

Hospitalization rates for intussusception in children aged 0-59 months from 2009 to 2014 in Italy

The real cause of intussusception is not fully understood and a variety of conditions have been associated with it (Meckel diverticulum, polyps, duplication cysts, parasites, Henoch-Schönlein purpura, cystic fibrosis, hemolytic-uremic syndrome and infectious gastroenteritis). Furthermore few European countries, following WHO recommendation to monitor baseline incidence of intussusception before implementation of immunization program for rotavirus, used intussusception rate as a baseline value to compare the same figures in the period before and after introduction of vaccination. In this study, data of intussusception hospitalizations occurred among Italian children aged 0 through 59 months from 2009 to 2014 were analyzed. A total amount of 3,088 children were included, accounting for a hospitalization rate of 20.2 per 100,000. Overall, the hospitalization rate for intussusception had a slight increase in trend from 2009 to 2014 (18%). In particular children 0-11 months had a hospitalization rate higher than 12-59 months with an aggregate value of 36 Vs. 16 per 100,000 respectively. Among all children hospitalized for intussusception a total of 239 (7.7%) had also a previous or concomitant hospitalization for gastroenteritis. This study demonstrates that Italian hospitalizations for intussusception are increasing by time and the role played by different risk factors, including acute gastroenteritis, have to be investigated in the future. These data could be useful to monitor intussusception hospitalization in the perspective of anti-rotavirus vaccination introduction in Italy.

Intussusception hospitalizations incidence in the pediatric population in Italy: a nationwide cross-sectional study

Background

Study to investigate the intussusception incidence background in the pediatric population and its temporal trend in Italy.

Methods

A cross-sectional study was conducted on the pediatric population aged 0 to 15 years, in the period 1 January 2002 to 31 December 2012. Intussusception cases were identified using the national hospital discharge database. The annual intussusception incidence, the incidence rate ratios (IRRs) and the related 95 % confidence Intervals (CI) were calculated.

Results

The overall intussusception incidence rate was 21 per 100,000 children aged ≤15 years, and was higher among boys than girls. The highest intussusception incidence rate occurred in infants <1 year of age (39 per 100,000 infants). Among infants, incidence varied with the geographical area, with higher rates in the central Italy (50 per 100,000 infants).

The annual incidence rates in infants were stable since 2004 and up to 2012, ranging from 40.1 and 33.0 per 100,000 infants. Similar stable patterns were observed when conducting the analysis on children over 1 year of age.

Conclusions

This study provided the intussusception incidence background in Italy in different pediatric ages, including infants, over an 11-year period. This information is essential in post-marketing safety surveillance, to continuously monitor the benefit/risk profile of rotavirus vaccinations.

Electronic supplementary material

The online version of this article (doi:10.1186/s13052-016-0298-8) contains supplementary material, which is available to authorized users.

Precise reply and clarifications on behalf of Sicilian Public Health Authorities to the case report published by La Rosa and collegues

As a results of the case report “Post-rotavirus vaccine intussusception in identical twins: a case report” recently published on Human Vaccines & Immunotherapy by La Rosa et al., the principal Sicilian Public Health Authorities decided to specify several points and underline some important details omitted by the authors. In particular, aims to underline the remarkable benefit for Sicilian Regional Health service after the introduction of the rotavirus vaccination. Universal mass vaccination against rotavirus is properly managed by the Regional Health Authorities and is contributing to a consistent increase of public health in the Sicilian pediatric population; any modification of such a program should be based on robust scientific evidences. Finally, a single case report should not be considered as a basis to recommend a change in the clinical practice but instead a possible point of start for discussion and research.

Analysis of hospitalizations due to intussusception in Sicily in the pre-rotavirus vaccination era (2003-2012)

BACKGROUND

Intussusception is the most common cause of bowel obstruction in infants with an incidence ranging from 9-328 cases per 100,000 infants aged 0-11 months. Causes underlining this clinical manifestation are still unknown. Possible relationship with a withdrawn tetravalent rotavirus vaccine was not confirmed by post-licensure studies and actually no increased risk of intussusception was found between infants vaccinated with both the recently licensed rotavirus vaccines. Aim of this study is to analyze the intussusception hospitalizations in Sicily from 2003 to 2012 before the introduction of rotavirus universal vaccination and its possible relation with rotavirus gastroenteritis trend.

METHODS

Were collected data from hospital discharge records occurred from 1(st) January 2003 to 31(st) December 2012 in Sicily. Intussusception cases were defined as all hospitalizations with an ICD-9-CM code of 560.0 on any discharge diagnoses. As a proxy for the severity of cases were considered ICD-9-CM procedure codes accounting for surgical or radiologic reduction.

RESULTS

A total of 340 intussusception cases were hospitalized in Sicily from 2003 to 2012 in children aged 0-59 months. 46.8 % occurred in the age class 0-11 months. Hospitalization rate for intussusception was 11.4 cases per 100,000 per year (32.6 cases per 100,000 among 0-11 months children; 7.3 cases per 100,000 among 12-59 months children), with a M:F sex ratio of 1.8. During hospitalization only 25 % of intussusceptions had a spontaneous resolution, 56.5 % of cases required a surgical intervention. From 2003 to 2012 intussusception cases were equally distributed during the year without any seasonality, while gastroenteritis hospitalizations due to rotavirus infection have a typically late winter and spring distribution.

CONCLUSIONS

In Sicily from 2003 to 2012 hospitalizations due to intestinal invagination were higher among children aged 0-11 months with observed rates similar to other European countries. Regional baseline data analysis of intussusception among 0-59 children is recognized as an evidence-based public health strategy by international health authorities. Indeed, this strategy is necessary to compare any post-licensure age or sex-related change in intussusception trend after universal rotavirus vaccination introduction.