Clinical trials of rotavirus vaccines in Europe

The respiratory syncytial virus prefusion F protein vaccine attenuates the severity of respiratory syncytial virus-associated disease in breakthrough infections in adults ≥60 years of age

Background

Respiratory syncytial virus (RSV) is a contagious pathogen causing acute respiratory infections (ARIs). Symptoms range from mild upper respiratory tract infections to potentially life-threatening lower respiratory tract disease (LRTD). In adults ≥60 years old, vaccine efficacy of a candidate vaccine for older adults (RSVPreF3 OA) was 71.7% against RSV-ARI and 82.6% against RSV-LRTD (AReSVi-006/NCT04886596). We present the patient-reported outcomes (PROs) from the same trial at the end of the first RSV season in the northern hemisphere (April 2022).

Methods

In this phase 3 trial, adults aged ≥60 years were randomized (1:1) to receive one dose of RSVPreF3 OA vaccine or placebo. PROs were assessed using InFLUenza Patient-Reported Outcome (FLU-PRO), Short Form-12 (SF-12), and EuroQol-5 Dimension (EQ-5D) questionnaires. Peak FLU-PRO Chest/Respiratory scores during the first 7 days from ARI episode onset were compared using a Wilcoxon test. Least squares mean (LSMean) of SF-12 physical functioning (PF) and EQ-5D health utility scores were estimated using mixed effects models.

Results

In the RSVPreF3 OA group (N = 12,466), 27 first RSV-ARI episodes were observed versus 95 in the Placebo group (N = 12,494). Median peak FLU-PRO Chest/Respiratory scores were lower in RSVPreF3 OA (1.07) versus Placebo group (1.86); p = 0.0258. LSMean group differences for the PF and EQ-5D health utility score were 7.00 (95% confidence interval [CI]: -9.86, 23.85; p = 0.4125) and 0.0786 (95% CI: -0.0340, 0.1913; p = 0.1695).

Conclusions

The RSVPreF3 OA vaccine, in addition to preventing infection, attenuated the severity of RSV-associated symptoms in breakthrough infections, with trends of reduced impact on PF and health utility.

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.

Implementation of the World Health Organization recommendation on the use of rotavirus vaccine without age restriction by African countries

The World Health Organization (WHO) recommended the worldwide use of rotavirus vaccines initially in 2007 and 2009 applying a strict age restriction criterion due to the potential for age-related association with increased risk of intussusception in infants. The restriction was relaxed in the 2013 after detailed review of robust safety data generated in post-marketing surveillance studies. We assessed the status of the implementation of the 2013 recommendation to remove age restriction in the WHO African region (AFR). Of the approximately 75% (35/47) of countries that had introduced the vaccine by 2018, only 43% (15/35) removed age restriction, exclusively from South and East sub-region (78%, 14/18). Avoiding confusion at the health facilities and financial constraints particularly resources required for re-training the health workers, use of vaccine off-label were cited as the main reasons for not implementing the 2013 WHO recommendation on age restriction removal. The 2013 WHO recommendation has not been fully implemented by African countries, suggesting the need for technical advisory bodies to further guide the countries, continue monitoring the implementation status and impact on the rotavirus vaccine coverage and intussusception in the Africa region.

Patient-reported outcomes in vaccines research: relevance for decision-making

The development and demand for effective vaccines have witnessed an exponential growth over the last century. In the meantime, the vaccine market involves more knowledgeable stakeholders, with a shift in emphasis by regulatory agencies on understanding the patient perception and experience. The Food and Drug Administration's publication of the patient-reported outcomes (PRO) guidance has elevated the discipline of PROs and has resulted in a transition from clinician reports of patient outcomes to PROs. This review reports various research methods, which utilize PROs, including qualitative and quantitative research, clinical trials, and patient preference studies. With the advancement of electronic PRO data capture, additional advantages of PROs are being observed and utilized (e.g. as a trigger for clinical endpoints). We discuss uses and advantages of including PROs into the clinical trial program to improve efficiencies, clinical relevance and overall validity of the program in the vaccine field. (See Plain Language Summary).

Quality of Life Impact of an Adjuvanted Recombinant Zoster Vaccine in Adults Aged 50 Years and Older

Background

To determine the efficacy of an adjuvanted recombinant zoster vaccine in reducing the herpes zoster (HZ) burden of illness, HZ burden of interference with activities of daily living, and HZ impact on quality of life.

Methods

The assessments were integrated in two Phase III trials, ZOE-50 (NCT01165177) and ZOE-70 (NCT01165229). HZ burden of illness and HZ burden of interference with activities of daily living were assessed by the Zoster Brief Pain Inventory (ZBPI) instrument and quality of life by the EuroQol-5 Dimension (EQ-5D) utility index and the SF-36 health survey. We report the ZOE-50 results and a pooled analysis of patients aged 70 years and older from the trials combined.

Results

The estimated vaccine efficacy in reducing HZ burden of illness and HZ burden of interference was greater than 90% in both the ZOE-50 and the pooled ZOE-70 analysis. In confirmed HZ cases, adjuvanted recombinant zoster vaccine reduced the maximal ZBPI worst-pain score in the pooled ZOE-70 analysis (p = .032) and the maximal ZBPI average-pain scores in both the ZOE-50 (p = .049) and the pooled ZOE-70 analysis (p = .043). In breakthrough HZ cases, trends for diminished loss of quality of life compared with placebo-recipient HZ cases were observed, with differences up to 0.14 on the EQ-5D index at time points during the 4 weeks following HZ onset.

Conclusions

Adjuvanted recombinant zoster vaccine reduced the HZ burden of illness significantly, particularly due to its very high vaccine efficacy in preventing HZ. For breakthrough HZ cases, the results suggest that the adjuvanted recombinant zoster vaccine mitigated severity of HZ-related pain, burden of interference with activities of daily living, and recipients’ utility loss.

Burden-of-illness vaccine efficacy

In recent years, many vaccines have been developed for the prevention of a variety of diseases. Although the primary objective of vaccination is to prevent disease, vaccination can also reduce the severity of disease in those individuals who develop breakthrough disease. Observations of apparent mitigation of breakthrough disease in vaccine recipients have been reported for a number of vaccine‐preventable diseases such as Herpes Zoster, Influenza, Rotavirus, and Pertussis. The burden‐of‐illness (BOI) score was developed to incorporate the incidence of disease as well as the severity and duration of disease. A severity‐of‐illness score S > 0 is assigned to individuals who develop disease and a score of 0 is assigned to uninfected individuals. In this article, we derive the vaccine efficacy statistic (which is the standard statistic for presenting efficacy outcomes in vaccine clinical trials) based on BOI scores, and we extend the method to adjust for baseline covariates. Also, we illustrate it with data from a clinical trial in which the efficacy of a Herpes Zoster vaccine was evaluated.

Risk of intussusception following rotavirus vaccination: An evidence based meta-analysis of cohort and case-control studies

BACKGROUND

International post-licensure studies on rotavirus vaccines have identified an increased risk of intussusception in infants after administration. The first developed rotavirus vaccine (Rotashield (RRV-TV)) was suspended post-licensure in 1999 after an association with intussusception was found. The currently available second-generation rotavirus vaccines (Rotateq (RV5) and Rotarix (RV1)), are recommended as a routine vaccine by the World Health Organisation (WHO). Post-licensure studies of these vaccines have shown a smaller but temporal increased risk for developing intussusception.

METHODS

A meta-analysis was performed to summarise available evidence and to give an overall risk of developing intussusception from case-control and cohort studies for all rotavirus vaccines that have been manufactured up to date. A search was conducted on MEDLINE, PubMed, EMBASE and Google Scholar up to May 2017. Eligible studies assessed the relationship between the rotavirus vaccine administration and subsequent development of intussusception both after receiving the first dose and after receiving all doses combined. Data was extracted on study characteristics, methods and outcomes. Results were pooled using the random-effect model.

RESULTS

Six cohort studies involving 4506265 total first doses and five case-control studies involving a total sample of 9643 children were included in this analysis. The cohort data revealed that there was an associated increased risk of intussusception after the first 7days post first dose of the vaccine (RR:3.71, 95% CI:1.08-12.69) and after receiving all doses of the rotavirus vaccine (RR:3.47, 95% CI:1.23-9.78). Similarly, the case-control data found an increased risk of intussusception following the first dose (OR: 8.45, 95% CI: 4.08-17.50) and following all doses (OR: 1.59, 95% CI: 1.11-2.27).

CONCLUSIONS

Findings of this meta-analysis suggest that the rotavirus vaccine is associated with an increased risk on the development of intussusception, principally seen after administration of the first dose of vaccine.

Issues in pediatric vaccine-preventable diseases in low- to middle-income countries

The highest burden of pediatric vaccine-preventable disease is found in developing nations where resource constraints pose the greatest challenge, impacting disease diagnosis and surveillance as well as the implementation of large scale vaccination programmes. In November 2012, a Working Group Meeting convened in Casablanca to describe and discuss the status with respect to 8 vaccine-preventable diseases (pertussis, pneumococcal disease, measles-mumps-rubella-varicella (MMRV), rotavirus and meningococcal meningitis) to identify and consider ways of overcoming obstacles to pediatric vaccine implementation. Experts from Europe, Russia, the Commonwealth of Independent States, the Middle East, Africa and South East Asia participated in the meeting. A range of region-specific needs and barriers to uptake were discussed. The aim of this article is to provide a summary of the ongoing status with respect to pediatric vaccine preventable disease in the countries represented, and the experts' opinions and recommendations with respect to pediatric vaccine implementation.

Cell culture-based viral vaccines: current status and future prospects

Cell culture-based viral vaccines are used globally to immunize humans against infections. The cell culture is continuous process of developing substrates for the safe production of viral vaccines. However, increased global demand and strict safety rules for novel vaccines to control and eradicate viral diseases have forced researchers and manufacturers toward cell culture-based vaccines. The choice of cell substrate is a critical step that cannot be generalized for every vaccine formulation, therefore, manufacturers intend to optimize the required processes for particular applications. The recently established cell lines, innovative bioreactor concepts and cultivation schemes are necessary to increase the potential of vaccine production. In this review, we have focused on current cell culture-based viral vaccines and their future prospects.

Tropical and travel-associated norovirus: current concepts

PURPOSE OF REVIEW

We highlight recent advances relevant to understanding norovirus infections in the tropics, both in populations living in developing settings and travelers to these regions.

RECENT FINDINGS

Because of the decrease in diarrheal disease associated with the global rollout of vaccines against rotavirus, norovirus is emerging as the predominant cause of diarrhea morbidity among children in the tropics, and evidence suggests that it contributes to adult disease in endemic populations and travelers. In addition to identifying potential target populations for preventive measures, we provide an update on norovirus vaccine development and concepts related to their implementation in low-income and middle-income countries.

SUMMARY

These current concepts related to norovirus-attributable disease burden, clinical significance, and economic impact can potentially be applied to tailoring efforts to prevent and mitigate the effects of this important enteropathogen.

Cost-Effectiveness of Rotavirus Vaccination for Under-Five Children in Iran

Background:

Rotavirus diarrhea is one of the most important causes of death among under-five children. Anti-rotavirus vaccination of these children may have a reducing effect on the disease.

Objectives:

this study is intended to contribute to health policy-makers of the country about the optimal decision and policy development in this area, by performing cost-effectiveness and cost-utility analysis on anti-rotavirus vaccination for under-5 children.

Patients and Methods:

A cost-effectiveness analysis was performed using a decision tree model to analyze rotavirus vaccination, which was compared with no vaccination with Iran’s ministry of health perspective in a 5-year time horizon. Epidemiological data were collected from published and unpublished sources. Four different assumptions were considered to the extent of the disease episode. To analyze costs, the costs of implementing the vaccination program were calculated with 98% coverage and the cost of USD 7 per dose. Medical and social costs of the disease were evaluated by sampling patients with rotavirus diarrhea, and sensitivity analysis was also performed for different episode rates and vaccine price per dose.

Results:

For the most optimistic assumption for the episode of illness (10.2 per year), the cost per DALY averted is 12,760 and 7,404 for RotaTeq and Rotarix vaccines, respectively, while assuming the episode of illness is 300%, they will be equal to 2,395 and 354, respectively, which will be highly cost-effective. Number of life-years gained is equal to 3,533 years.

Conclusions:

Assuming that the illness episodes are 100% and 300% for Rotarix and 300% for Rota Teq, the ratio of cost per DALY averted is highly cost-effective, based on the threshold of the world health organization (< 1 GDP per capita = 4526 USD). The implementation of a national rotavirus vaccination program is suggested.

A Qualitative Study of the Status of Children's Play From the Viewpoints of Experts and Suggestions for Promotion Interventions

BACKGROUND

The latest national census reports the population of Iranian children (1 - 8 years old) about 11 millions. On the other hand, the latest population policies approved by supreme cultural revolution council (SCRC) will make this population increase faster. Childhood development is one of the social determinants of health, of which "child's play" is a part.

OBJECTIVES

This study is an effort to identify difficulties and challenges of the plays influential on Iranian children's health nationwide, in order to present enhancive strategies by utilizing the views of stakeholders and national studies.

PATIENTS AND METHODS

Analyzing children's play stakeholders, main organizations were identified and views of 13 informed people involved in the field were investigated through deep semi-structured interview. A denaturalized approach was employed in analyzing the data. In addition to descriptions of the state, interventions development, and designing the conceptual model, national reports and studies, and other countries' experiences were also reviewed.

RESULTS

Society's little knowledge of "children's plays", absence of administrators for children's play, shortage of public facilities for children's play and improper geographical and demographic availability, absence of policies for Iranian "toy", and little attention of media to the issue are the five major problems as stated by interviewees.

CONCLUSIONS

The proposed interventions are presented as "promoting the educational levels of parents and selected administrators for children's play", "approving the play and toy policy for Iran 2025", and "increasing public facilities for children's play with defined distribution and availability".

Family impact of Rotavirus Gastroenteritis in Taiwan and Vietnam: an Ethnographic Study

Background

Prior to the introduction of rotavirus vaccines, rotavirus was the leading cause of severe gastroenteritis in infants and young children, and it continues to be the leading cause in countries without vaccination programs. Rotavirus gastroenteritis results in substantial economic burden and has a pronounced effect on the family of those who are ill. Both in Taiwan and in Vietnam, rotavirus illness is viewed as a priority disease. This study assessed, in Taiwan and Vietnam, the impact of rotavirus gastroenteritis on the family among a group of parents whose children had recently been hospitalized for this illness.

Methods

In the first half of 2013, parents of children who had been hospitalized due to rotavirus infection were recruited from hospitals in Taiwan (n = 12) and Vietnam (n = 22), and participated in focus group sessions or in-depth ethnographic interviews.

Results

In both countries, the results point to a substantial burden on the parents concerning emotions and logistics of daily tasks, and to considerable disruptions of the family routine. Taiwanese parents reported satisfaction with the health care system, a great deal of effort to suppress emotions, a fair amount of knowledge about rotavirus, and little extra costs related to the illness. On the other hand, parents in Vietnam expressed concern about the emotional well-being of and the health care treatments for their children, were less knowledgeable regarding rotavirus infection, and experienced a substantial financial burden due to indirect costs that were related to accessing treatment.

Conclusions

Families in Taiwan and Vietnam suffer from a considerable economic and emotional burden related to rotavirus gastroenteritis. One way to substantially reduce this burden is to provide universal and affordable rotavirus vaccination to susceptible children, especially since cost-effectiveness studies have demonstrated that universal vaccination would be safe and efficacious against severe rotavirus gastroenteritis in these countries.

Rotavirus vaccine effectiveness and case-control study on risk factors for breakthrough infections in Germany, 2010-2011

BACKGROUND

In the German federal state Mecklenburg-Western Pomerania, routine rotavirus (RV) vaccination in infants has been recommended since 2009. The effectiveness of RV vaccination was investigated after an unexpectedly high number of RV infections in fully vaccinated children occurred.

METHODS

Intensified RV surveillance was performed in Mecklenburg-Western Pomerania between 2010 and 2011. The screening method was applied to assess vaccine effectiveness (VE) in children up to 24 months after vaccination. To identify risk factors for breakthrough infections, a case-control study and genotyping were conducted in vaccinated and unvaccinated RV-infected children.

RESULTS

VE for the prevention of RV infection requiring medical attention or hospitalization was 68% (95% confidence interval [CI]: 61-71) and 80% (95% CI: 77-83), respectively. VE for preventing hospitalization but not medical attention remained stable over 2 years. Vaccinated were less often hospitalized (23%) than unvaccinated RV-infected children (61%; P < 0.001). Breastfeeding (odds ratio, 3.99; 95% CI: 1.92-8.27) and attending daycare (odds ratio, 3.42; 95% CI: 1.64-7.12) were independently associated with breakthrough infections. Genotype G1P[8] was detected more frequently in RotaTeq-vaccinated (44% versus 11%; P < 0.03) and G2P[4] in Rotarix-vaccinated children (42% versus 6%; P < 0.02).

CONCLUSIONS

RV vaccination protects young children effectively from RV disease and can reduce disease severity. Breastfeeding might impair VE, but further research is needed to identify the critical time window for this interference and to develop appropriate recommendations.

New insights in mucosal vaccine development

Mucosal surfaces are the major entrance for infectious pathogens and therefore mucosal immune responses serve as a first line of defence. Most current immunization procedures are obtained by parenteral injection and only few vaccines are administered by mucosal route, because of its low efficiency. However, targeting of mucosal compartments to induce protective immunity at both mucosal sites and systemic level represents a great challenge. Major efforts are made to develop new mucosal candidate vaccines by selecting appropriate antigens with high immunogenicity, designing new mucosal routes of administration and selecting immune-stimulatory adjuvant molecules. The aim of mucosal vaccines is to induce broad potent protective immunity by specific neutralizing antibodies at mucosal surfaces and by induction of cellular immunity. Moreover, an efficient mucosal vaccine would make immunization procedures easier and be better suited for mass administration. This review focuses on contemporary developments of mucosal vaccination approaches using different routes of administration.

Oral immunoglobulin for the prevention of rotavirus infection in low birth weight infants

BACKGROUND

Rotavirus is a common neonatal nosocomial viral infection and epidemics with the newer P(6)G9 strains have been reported. Local mucosal immunity in the intestine to rotavirus is important in the resolution of infection and protection against subsequent infections. Oral administration of anti-rotaviral immunoglobulin preparations might be a useful strategy in preventing rotaviral infections, especially in low birth weight babies.

OBJECTIVES

To determine the effectiveness and safety of oral immunoglobulin preparations for the prevention of rotavirus infection in hospitalized low birthweight infants (birthweight < 2500 g)

SEARCH METHODS

The Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library), MEDLINE, EMBASE, CINAHL, biological Abstracts (BIOSIS), Science Citation Index for articles citing Barnes 1982 and the proceedings of the Pediatric Academic Societies from 1991 onwards were searched in July 2011. Ongoing trials were also searched at clinicaltrials.gov and controlled-trials.com

SELECTION CRITERIA

The criteria used to select studies for inclusion were: 1) design: randomized or quasi-randomized controlled trials; 2) participants: hospitalized low birthweight infants; 3) intervention: oral immunoglobulin preparations for prevention of rotavirus infection compared to placebo OR no intervention; 4) at least one of the following outcomes were reported: all cause mortality during hospital stay, mortality due to rotavirus infection during hospital stay, rotavirus infection , duration of diarrhea, need for rehydration, duration of viral excretion, duration of infection control measures, length of hospital stay in days, recurrent diarrhea or chronic diarrhea.

DATA COLLECTION AND ANALYSIS

The two review authors independently abstracted data from the included trials.

MAIN RESULTS

One published study (Barnes 1982) was eligible for inclusion in this review. Barnes 1982 found no significant difference in the rates of rotavirus infection after oral gammaglobulin versus placebo in hospitalized low birthweight babies [RR 1.27 (95% CI 0.65 to 2.37)]. In the subset of infants who became infected with rotavirus after receiving gammaglobulin or placebo for prevention of rotavirus infection, there was no significant difference in the duration of rotavirus excretion between the group who had gammaglobulin (mean 2 days, range 1 to 4 days) and the group who had placebo (mean 3 days, range 1 to 6 days). Barnes 1982 reported no adverse effects after administration of oral immunoglobulin preparations.

AUTHORS' CONCLUSIONS

Current evidence does not support the use of oral immunoglobulin preparations to prevent rotavirus infection in low birthweight infants. Researchers are encouraged to conduct well-designed neonatal trials using the newer preparations of anti-rotaviral immunoglobulins (colostrum, egg yolk immunoglobulins) and include cost effectiveness evaluations.

Oral immunoglobulin for the treatment of rotavirus diarrhea in low birth weight infants

BACKGROUND

Rotavirus infection is the most common neonatal nosocomial viral infection. It is a major health problem worldwide. Epidemics with the newer P(6)G9 strains have been reported in neonatal units globally. These strains can cause severe symptoms in most infected infants. Infection control measures become necessary and the utilization of hospital resources increase. Local mucosal immunity in the intestine to rotavirus is important in the resolution of infection and protection against subsequent infections. Boosting local immunity by oral administration of anti-rotaviral immunoglobulin preparations might be a useful strategy in treating rotaviral infections, especially in low birth weight babies.

OBJECTIVES

To determine the effectiveness and safety of oral immunoglobulin preparations for the treatment of rotavirus diarrhea in hospitalized low birth weight infants (birth weight less than 2500 g)

SEARCH STRATEGY

Electronic databases including The Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 3, 2004), MEDLINE, EMBASE and CINAHL, Biological Abstracts (BIOSIS) were searched by the strategy outlined in the protocol. Science Citation Index search for all articles that referenced Barnes 1982 were searched. The proceedings of the Pediatric Academic Societies published online at 'Abstracts Online' were searched. Ongoing registered trials at www.clinicaltrials.gov and www.controlled-trials.com were searched. Authors prominent in the field were contacted for any unpublished articles and more information on published articles was sought. Reference lists of identified clinical trials and personal files were also reviewed. The above search was updated in July 2011.

SELECTION CRITERIA

The criteria used to select studies for inclusion were: 1) DESIGN: randomized or quasi-randomized controlled trials 2) Hospitalized low birth weight infants with rotavirus diarrhea 3) INTERVENTION: Oral immunoglobulin preparations compared to placebo or no intervention 4) At least one of the following outcomes were reported: All cause mortality during hospital stay, mortality due to rotavirus infection during hospital stay, duration of diarrhea, need for rehydration, duration of viral excretion, duration of infection control measures, length of hospital stay in days, recurrent diarrhea or chronic diarrhea

DATA COLLECTION AND ANALYSIS

The two reviewers were to independently abstract data from eligible trials. No data were available for analysis.

MAIN RESULTS

No eligible randomized controlled trials were found.

AUTHORS' CONCLUSIONS

No randomized controlled trials that assessed the effectiveness or safety of oral immunoglobulin preparations for the treatment of rotavirus diarrhea in hospitalized low birth weight infants were found. Clinical trials that address the issue of oral immunoglobulin treatment of rotavirus infection are needed.

Gastroenteritis in childhood: a retrospective study of 650 hospitalized pediatric patients

BACKGROUND

Acute diarrhea continues to be an important cause of hospitalization in young children, and deaths still occur as a result. We reviewed a large cohort of hospitalized children affected by gastroenteritis. The hypothesis of our study was that clinical characteristics and a limited set of laboratory data can differentiate between the different causative pathogens of diarrhea.

METHODS

A chart review was performed of 650 patients with pathogen-proven diarrhea treated between April 2005 and May 2008 in the children's hospital of the University of Würzburg. Clinical presentation at the time of admission and during hospital stay, laboratory findings, stool pathogen results, and epidemiological data were collected and compared. A severity score was generated.

RESULTS

Rotavirus was the most common gastroenteritis pathogen identified, followed by norovirus, adenovirus and Salmonella spp. Nosocomial infections were caused most commonly by norovirus. Rotavirus was the most common agent when there was simultaneous detection of two or more viruses. Rotavirus infections were significantly more severe, with a higher frequency of diarrhea and elevated liver enzymes. Infections due to Salmonella spp showed significantly higher values for C-reactive protein, erythrocyte sedimentation rate, and body temperature. A seasonal distribution was noted, with the peak for rotaviruses/noroviruses in winter/spring, the peak for adenoviruses in November/December, and the peak for Salmonella spp in the summer months. Younger children and toddlers had significantly higher gastroenteritis and airway inflammation scores. Of note, respiratory symptoms and parameters of systemic inflammation differed between the different pathogens.

CONCLUSIONS

Gastroenteritis is a common reason for hospital admission in previously healthy children during the first years of life. Rotaviruses were found to be the most common pathogens in our cohort. On the basis of clinical and laboratory parameters it appears possible to distinguish between the different causative agents. This may have implications for hospital hygiene management and for the identification of predictive markers of a severe course.

Is it cost-effective to introduce rotavirus vaccination in the Dutch national immunization program?

This study assessed whether the inclusion of two rotavirus (RV) vaccines in the Dutch national immunization programme is cost-effective. Costs and outcomes in unvaccinated and vaccinated populations are compared for a time period of 20 years. In the baseline, assuming competitive market forces in relation to vaccine costs, Rotarix is more cost-effective than RotaTeq, resulting in a cost-utility ratio (CUR) of euro 53,000 per DALY (third payer perspective) and euro 49,000 per DALY (societal perspective), but both considered as being not cost-effective. Vaccine-related costs, annual epidemic-size, and indirect protection are the major factors that determine cost-effectiveness of RV vaccination.

Vero cell platform in vaccine production: moving towards cell culture-based viral vaccines

The development of cell culture systems for virus propagation has led to major advances in virus vaccine development. Primary and diploid cell culture systems are now being replaced by the use of continuous cell lines (CCLs). These substrates are gaining increasing acceptance from regulatory authorities as improved screening technologies remove fears regarding their potential oncogenic properties. The Vero cell line is the most widely accepted CCL by regulatory authorities and has been used for over 30 years for the production of polio and rabies virus vaccines. The recent licensure of a Vero cell-derived live virus vaccine (ACAM2000, smallpox vaccine) has coincided with an explosion in the development of a range of new viral vaccines, ranging from live-attenuated pediatric vaccines against rotavirus infections to inactivated whole-virus vaccines against H5N1 pandemic influenza. These developments have illustrated the value of this cell culture platform in the rapid development of vaccines against a range of virus diseases.

Infantile gastroenteritis in the community: a cost-of-illness study

Rotavirus infections are the main cause of gastroenteritis in infants and children and it is expected that by the age of 5 years, nearly every child will have experienced at least one episode of rotavirus gastroenteritis. While severe cases are hospitalized, milder disease is either treated at home or by the GP, and as such the true prevalence of rotavirus infection in the community, and the burden of disease, is unknown. This paper reports the results of a cost-of-illness study which was conducted alongside a structured community surveillance study. Forty-eight percent of our sample was found to have rotavirus acute gastroenteritis; and the average total cost of a child presenting with rotavirus gastroenteritis ranged between pound sterling 59 and pound sterling 143 per episode, depending on the perspective. Given the prevalence and severity of the disease, the estimated burden of rotavirus gastroenteritis to society is pound sterling 11.5 million per year.

Viral Diarrhea

Viral gastroenteritis is among the most common illnesses affecting humans and has greatest impact at the extremes of age. The spectrum of disease can range from asymptomatic infections to severe disease with dehydration. Intensive investigation of enteric infections in the past three decades has made it increasingly clear that viruses cause a significant proportion of enteric illnesses worldwide. In contrast to bacterial pathogens, enteric viruses cannot multiply outside their host; hence, the original inoculum into the common source determines infectivity. Prevention of contamination of food and water will help control primary cases, whereas careful nursing and handwashing prevent secondary cases.

Exploring the cost effectiveness of an immunization programme for rotavirus gastroenteritis in the United Kingdom

Rotavirus is the most common cause of gastroenteritis in children aged <5 years old, two new vaccines have recently been developed which can prevent associated morbidity and mortality. While apparently safe and efficacious, it is also important to establish whether rotavirus immunization is cost effective. A decision analytical model which employs data from a review of published evidence is used to determine the cost effectiveness of a rotavirus vaccine. The results suggest that some of the health sector costs, and all of the societal costs, of rotavirus gastroenteritis in children can be avoided by an immunization programme. The additional cost to the health sector may be considered worthwhile if there is a sufficient improvement in the quality-of-life of children and parents affected by gastroenteritis; this study did not find any evidence of research which has measured the utility gains from vaccination.

Rotavirus vaccines in developed countries

PURPOSE OF REVIEW

Rotavirus is the most common cause of diarrhoea and dehydration in early childhood. The recent licensure in many nations of vaccines against rotavirus offers promise to significantly reduce this toll. The present review describes recent developments regarding rotavirus vaccines and the challenges they face.

RECENT FINDINGS

Rotavirus causes significant morbidity and impact upon healthcare systems, at both inpatient and outpatient levels. An earlier rotavirus vaccine, since withdrawn, was temporally associated with intussusception causing small bowel obstruction, especially in infants receiving their first dose at an older age. Large-scale safety and efficacy studies of two new live, oral, attenuated vaccines have shown excellent efficacy against severe rotavirus gastroenteritis. Importantly, both studies detected no association with intussusception with these new vaccines when administered at the scheduled ages. Developed using different rotavirus vaccinology philosophies, questions remain regarding their coverage against new rotavirus serotypes. Ongoing intussusception surveillance following introduction should answer whether they may be safely administered beyond scheduled ages.

SUMMARY

Safe, efficacious rotavirus vaccines are available in many developed countries, offering significant promise to reduce the burden of gastroenteritis and dehydration. The impact of these vaccines upon not only morbidity, but also circulating rotavirus serotypes, will be monitored with interest.

Oral administration of live virus protects susceptible mice from developing Theiler's virus-induced demyelinating disease

Intracerebral infection of susceptible mouse strains with Theiler's murine encephalomyelitis virus (TMEV) results in an immune-mediated demyelinating disease similar to human multiple sclerosis. TMEV infection is widely spread via fecal-oral routes among wild mouse populations, yet these infected mice rarely develop clinical disease. Oral vaccination has often been used to protect the host against many different infectious agents, although the underlying protective mechanism of prior oral exposure is still unknown. To understand the mechanisms involved in protection from demyelinating disease following previous oral infection, immune parameters and disease progression of mice perorally infected with TMEV were compared with those of mice immunized intraperitoneally following intracerebral infection. Mice infected perorally, but not intraperitoneally, prior to CNS viral infection showed lower chronic viral persistence in the CNS and reduced TMEV-induced demyelinating disease. However, a prolonged period of post-oral infection was necessary for effective protection. Mice orally pre-exposed to the virus displayed markedly elevated levels of antibody response to TMEV in the serum, although T cell responses to TMEV in the periphery were not significantly different between perorally and intraperitoneally immunized mice. In addition, orally vaccinated mice showed higher levels of early CNS-infiltration of B cells producing anti-TMEV antibody as well as virus-specific CD4(+) and CD8(+) T cells in the CNS compared to intraperitoneally immunized mice. Therefore, the generation of a sufficient level of protective immune responses appears to require a prolonged time period to confer protection from TMEV-induced demyelinating disease.

An age-structured epidemic model of rotavirus with vaccination

The recent approval of a rotavirus vaccine in Mexico motivates this study on the potential impact of the use of such a vaccine on rotavirus prevention and control. An age-structured model that describes the rotavirus transmission dynamics of infections is introduced. Conditions that guarantee the local and global stability analysis of the disease-free steady state distribution as well as the existence of an endemic steady state distribution are established. The impact of maternal antibodies on the implementation of vaccine is evaluated. Model results are used to identify optimal age-dependent vaccination strategies. A convergent numerical scheme for the model is introduced but not implemented. This paper is dedicated to Prof. K. P. Hadeler, who continues to push the frontier of knowledge in mathematical biology.

Oral immunoglobulin for the prevention of rotavirus infection in low birth weight infants

BACKGROUND

Rotavirus infection is the most common neonatal nosocomial viral infection. Epidemics with the newer P(6)G9 strains have been reported in neonatal units worldwide. These strains can cause severe symptoms in infected infants. Infection control measures become necessary and the utilisation of hospital resources increase. Local mucosal immunity in the intestine to rotavirus is important in the resolution of infection and protection against subsequent infections. Boosting local immunity by oral administration of anti-rotaviral immunoglobulin preparations might be a useful strategy in preventing rotaviral infections, especially in low birth weight babies.

OBJECTIVES

To determine the effectiveness and safety of oral immunoglobulin preparations for the prevention of rotavirus infection in hospitalised low birthweight infants (birth weight less than 2500 gms)

SEARCH STRATEGY

The Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 2, 2002), MEDLINE, EMBASE and CINAHL were searched. Science Citation Index was searched for all articles which referenced Barnes 1982. The proceedings of the Pediatric Academic Societies which were published in the journal, Pediatric Research from 1991 onwards were searched as well as abstracts of doctoral dissertations and theses from 1960 onwards. The above mentioned search strategy was completed in June 2002. Authors prominent in the field were contacted for any unpublished articles and more information on published articles was sought. Reference lists of identified clinical trials and personal files were reviewed.

SELECTION CRITERIA

The criteria used to select studies for inclusion were: 1) DESIGN: randomised or quasi-randomised controlled trials. 2) PARTICIPANTS: Hospitalised low birthweight infants. 3) INTERVENTION: Oral immunoglobulin preparations for prevention of rotavirus infection compared to placebo OR no intervention. 4) At least one of the following outcomes were reported: All cause mortality during hospital stay, mortality due to rotavirus infection during hospital stay, rotavirus infection, duration of diarrhoea, need for rehydration, duration of viral excretion, duration of infection control measures, length of hospital stay in days, recurrent diarrhoea or chronic diarrhoea.

DATA COLLECTION AND ANALYSIS

The two reviewers independently abstracted data from the included trials

MAIN RESULTS

One published study (Barnes 1982) was eligible for inclusion in this review. Two additional studies are awaiting assessment re eligibility for inclusion. Barnes 1982 found no significant difference in the rates of rotavirus infection after oral gammaglobulin versus placebo in hospitalised low birthweight babies [RR 1.27 (95% CI 0.65-2.37)]. In the subset of infants who became infected with rotavirus after receiving gammaglobulin or placebo for prevention of rotavirus infection, there was no significant difference in the duration of rotavirus excretion between the group who had gammaglobulin (mean 2 days, range 1-4 days) and the group who had placebo (mean 3 days, range 1-6 days). No adverse effects were reported by Barnes 1982 after administration of oral immunoglobulin preparations.

REVIEWER'S CONCLUSIONS

Current evidence from one randomised controlled trial does not support the routine use of oral immunoglobulin preparations for the prevention of rotavirus infection in low birth-weight infants. However, newer immunoglobulin preparations which have been found to be effective in older children have not been tested in neonatal trials. Therefore, researchers should be encouraged to conduct well designed trials in neonates at risk for rotavirus infections using the newer preparations of anti-rotaviral immunoglobulins (colostrum, egg yolk immunoglobulins). Such trials should also include cost effectiveness evaluations.

Oral immunoglobulin for the treatment of rotavirus infection in low birth weight infants

BACKGROUND

Rotavirus infection is the most common neonatal nosocomial viral infection. Epidemics with the newer P(6)G9 strains have been reported in neonatal units worldwide. These strains can cause severe symptoms in most infected infants. Infection control measures become necessary and the utilisation of hospital resources increase. Local mucosal immunity in the intestine to rotavirus is important in the resolution of infection and protection against subsequent infections. Boosting local immunity by oral administration of anti-rotaviral immunoglobulin preparations might be a useful strategy in treating rotaviral infections, especially in low birth weight babies.

OBJECTIVES

To determine the effectiveness and safety of oral immunoglobulin preparations for the treatment of rotavirus infection in hospitalised low birthweight infants (birth weight less than 2500 gms)

SEARCH STRATEGY

Electronic databases including The Cochrane Controlled Trials Register (The Cochrane Llibrary, Issue 2, 2002), MEDLINE (1966 - June 2002), EMBASE (1980 - June 2002) and CINAHL (1982 - June 2002) were searched by the strategy outlined in the protocol. Science Citation Index search for all articles which referenced Barnes 1982 were searched. The proceedings of the Pediatric Academic Societies which were published in the journal, Pediatric Research, from 1991 were searched as well as abstracts of the doctoral dissertations and theses from 1960. All of the above search strategies were completed in June 2002. Authors prominent in the field were contacted for any unpublished articles and more information on published articles was sought. Reference lists of identified clinical trials and personal files were also reviewed.

SELECTION CRITERIA

The criteria used to select studies for inclusion were: 1) DESIGN: randomised or quasi-randomised controlled trials 2) Hospitalised low birthweight infants with rotavirus infection 3) INTERVENTION: Oral immunoglobulin preparations compared to placebo OR no intervention 4) At least one of the following outcomes were reported: All cause mortality during hospital stay, mortality due to rotavirus infection during hospital stay, duration of diarrhoea, need for rehydration, duration of viral excretion, duration of infection control measures, length of hospital stay in days, recurrent diarrhoea or chronic diarrhoea

DATA COLLECTION AND ANALYSIS

The two reviewers were to independently abstract data from eligible trials. No data analysis was possible at this point.

MAIN RESULTS

No eligible randomised controlled trials were found.

REVIEWER'S CONCLUSIONS

We found no randomised controlled trials which assessed the effectiveness or safety of oral immunoglobulin preparations for the treatment of rotavirus infections in hospitalised low birthweight infants.