Rotavirus vaccination and intussusception: can we decrease temporally associated background cases of intussusception by restricting the vaccination schedule?

Abstract

OBJECTIVE: The first rotavirus vaccine that was licensed in the United States, RotaShield, could have prevented the enormous burden of rotavirus diarrhea in American children but left instead the unfortunate legacy that live oral rotavirus vaccines may be associated with a serious but rare adverse event: intussusception. Although large trials indicate that the next generation of rotavirus vaccines is not associated with this complication, many children likely will develop intussusception by chance alone in the 2-week window after immunization, raising concerns about whether these cases might be "caused" by the vaccine. Our objective for this study was to model and compare the number of temporally associated intussusception events that are expected by chance alone under 2 rotavirus vaccination strategies. METHODS: We used national vaccine coverage rates and age-specific incidence of intussusception by months to model the number of temporally associated cases of intussusception that are expected by chance alone for 2 potential vaccination strategies: a strict schedule, limiting immunization to children within 1 month of the designated age for each dose (ie, 60-89, 120-149, and 180-209 days for doses 1, 2, and 3, respectively) versus a free schedule whereby infants are immunized whenever they appear for their routine vaccines up to 1 year of age. RESULTS: The number of intussusception events during the 2-week postvaccination window was 24% lower for the strict versus the free schedule (138 vs 182, respectively). This reduction was attributable largely to the smaller number of infants who were immunized fully under the strict schedule (vaccine coverage for 3 doses, 67% vs 89%). The cumulative risk for intussusception's occurring by chance in the 2-week postvaccination window essentially was the same between schedules (4.59 vs 4.76 per 100000 doses). Most cases occurred after the second or third dose. CONCLUSIONS: Although an age-restricted vaccination schedule substantially reduced the number of intussusception events that were observed in the 2-week postvaccination window when compared with a schedule with fewer restrictions, this decrease was attributable to a lower rate of vaccine coverage rather than a safer schedule of vaccination. The risk for intussusception did not differ significantly between vaccination strategies. Public health policy and education messages for physicians and parents should be developed to anticipate intussusception events that will occur by chance alone but are temporally related to rotavirus vaccination.