Information sheet on the rotavirus vaccination

Being informed about the rotavirus vaccination has a problem no other has: it has to happen when the child is six weeks old – at a time, that is, when parents have little capacity for decisions. And it concerns the only vaccination that cannot be caught up. Which is why this conversation belongs before the birth.

What it is about

Rotaviruses are the commonest trigger of severe diarrhoeal illness in infants and small children. Before the vaccination was introduced, practically every child had at least one infection by its fifth birthday; rotaviruses were the commonest reason for admission to hospital because of diarrhoea in this age group.

What is dangerous is not the diarrhoea itself but the loss of fluid. An infant has smaller reserves than an older child and can become dehydrated within a few hours. The illness and its treatment are described in detail on the page rotavirus.

The virus is transmitted by the faecal-oral route via hands and objects. It is extraordinarily infectious – ten virus particles are enough for an infection – and survives on surfaces for days. From this follows a point that regularly frustrates parents: hygiene alone does not prevent a rotavirus infection.

The vaccine is not injected but swallowed. It is a live vaccine with attenuated viruses which triggers an immune response in the intestine – that is, where the infection would later take place. That is a substantial difference from all the other vaccinations of the first year of life, which are inactivated vaccines, and it has consequences that belong in this conversation.

The deadlines – the most important point

With no other vaccination is the timing so unrelenting. The deadlines are not a guide but a limit.

If the start is missed, the vaccination can no longer be caught up. That sets it apart from practically all the others: with the six-in-one vaccination an interrupted series is continued, even after years; here there is no second opportunity.

The reason is the risk of intussusception, which rises slightly with the child's age. Within the window it is very small; outside it, it is no longer accepted.

From this deadline follows the practical advice at the start of this page: the decision should be taken before the birth. Anyone who postpones it to the time after delivery postpones it into exactly those weeks in which lack of sleep is greatest – and in case of doubt loses the opportunity.

Intussusception in detail

This is the point about which you have to be informed with this vaccination, and it deserves precision rather than a reassuring formula.

In an intussusception one section of bowel telescopes into the next. It occurs without any vaccination too, most often between the third and ninth month of life, and is a paediatric surgical emergency.

The first rotavirus vaccine was withdrawn from the market after a short time in 1999, because it markedly increased the frequency. The vaccines used today were subsequently tested in studies each involving more than 60,000 infants. They show a very small additional risk: one to six additional cases per 100,000 vaccinated children, and practically only in the seven days after the first dose.

Set against this is what the vaccination prevents: in Austria admissions to hospital because of rotavirus diarrhoea have fallen by more than eighty per cent since the programme was introduced.

Warning signs in the days after the vaccination that belong in a children's hospital immediately: attacks of shrill crying with the legs drawn up; repeated vomiting; marked pallor; listlessness between the attacks; stool resembling redcurrant jelly. Recognised early, an intussusception can usually be resolved without an operation.

What a live vaccine means in the household

After the oral vaccine the vaccine virus is excreted in the stool, above all in the first week. For healthy members of the household this is of no significance – careful handwashing after changing nappies is enough.

It is different if someone with severely weakened immune defences lives in the household: after an organ transplant, on chemotherapy, with a congenital immune deficiency. Then it belongs discussed before the vaccination. In most cases the vaccination is given nonetheless, with stricter hygiene measures – the alternative would be for the child to have a genuine rotavirus infection and excrete considerably more virus in the process.

The vaccination is not given with a severe immune deficiency in the child itself, with a known malformation of the digestive tract that favours intussusception, and with a history of intussusception. With an acute, severe diarrhoeal illness it is postponed – here, however, with an eye on the deadline, which does not wait.

The other side effects

Common – in up to one in ten vaccinated children: irritability, diarrhoea, occasionally vomiting or wind. These reactions are mild and subside within a few days.

Uncommon: fever, loss of appetite, abdominal pain.

Rare to very rare: allergic reactions; in very immature premature babies pauses in breathing have been observed in the first days after the vaccination, which is why these children are occasionally vaccinated as inpatients.

Compared with the injected vaccinations of the first year of life, the oral rotavirus vaccine is one of the best tolerated – and the only one without a needle. For many parents it is therefore the least eventful appointment of the first six months: the child receives a small amount of liquid into the pouch of the cheek and as a rule notices nothing about it.

What to watch for in the days afterwards

Because the vaccination works in the intestine, the signs to watch for are different from those after an injected vaccination. There is no injection site, no typical post-vaccination fever, no tender thigh.

Normal in the first days: somewhat looser stools, irritability, an unusually restless evening, occasionally wind or slight vomiting. These signs are mild and disappear by themselves.

To be watched for in the seven days after the first dose is the possibility of an intussusception. The signs differ clearly from a usual reaction to a vaccination: attacks of shrill crying in which the child draws its legs up, with quiet stretches in between; repeated vomiting; marked pallor; listlessness; bloody, mucous stool.

The feature that distinguishes this situation from ordinary stomach ache is the pattern of attacks: phases of violent crying alternating with striking quiet. With this picture the child belongs in a children's hospital without delay – not in a practice and not in waiting and seeing.

This list is not meant to frighten. The probability is a few cases per hundred thousand vaccinated children. It is here because an intussusception recognised early can usually be resolved without an operation and one recognised late cannot – and because that is exactly why you are informed about it.

Practical points for the appointment

Breastfeeding is possible without restriction, before and after the vaccination. A pause in breastfeeding is not necessary; older recommendations to the contrary are outdated.

If the child spits the dose out, it is not repeated. The licensing studies were carried out without re-dosing, and effectiveness was there nonetheless.

Other vaccinations on the same day are possible and usual – in Austria the second rotavirus dose mostly coincides with the first appointment for the six-in-one vaccination.

A mild infection without fever is no obstacle. Because of the tight deadlines, postponement here is handled more cautiously than with other vaccinations: a postponement can end the opportunity altogether.

Premature babies are vaccinated according to their actual age, not their corrected age. A child born eight weeks early therefore also gets its first dose from the sixth week of life – it is precisely children born too early who fall particularly severely ill, and the window does not wait.

What the vaccination achieves

Complete information also includes the benefit side, and with this vaccination it is unusually well documented – because the illness was so common that changes showed up quickly in the hospital statistics.

Against severe courses the vaccination protects to about 85 to 98 per cent, against any rotavirus infection to about 74 per cent. A vaccinated child can therefore certainly get rotavirus diarrhoea – only as a rule it runs a course that can be managed at home.

In Austria the vaccination was introduced nationwide in 2007, as one of the first countries in Europe. Admissions to hospital because of rotavirus diarrhoea subsequently fell by more than eighty per cent.

There is an additional effect that is easily overlooked in an individual decision: vaccinated children excrete fewer viruses, which lowers the frequency of illness in unvaccinated children and in adults around them as well. In countries with high participation this can be clearly read off the statistics.

And seen worldwide it is about more than hospital admissions avoided: in countries without good access to medical care, rotaviruses were long one of the commonest causes of death in small children. Since immunisation programmes were introduced, that number has fallen by several hundred thousand a year.

What the conversation has to contain

The requirements are the same for every vaccination and in Austria have been shaped by case law: the illness and its consequences, the benefit of the vaccination, the procedure, the possible side effects with an indication of frequency and the consequences of refusing – plus an opportunity to ask questions and enough time to think it over.

The signed form is not the information but its documentation. Legally it is the conversation that counts. More on this and on the question of who may consent in Austria is on the page information sheet on the six-in-one vaccination.

With this vaccination there is a particularity that belongs expressly named: the consequence of a postponement is not a later vaccination but none at all. That is not the case with any other vaccination in the programme, and it is regularly overlooked.

If the child gets diarrhoea despite the vaccination

That happens, and it is not a sign that the vaccination has failed: it protects reliably against severe courses, less reliably against every infection. Besides, there are numerous other causes of diarrhoea against which it does nothing – noroviruses, adenoviruses and bacterial organisms.

The most important thing at home is fluid. Keeping breastfeeding is the most effective measure; breast milk contains fluid, salts and nutrients in exactly the right composition and is absorbed even by an inflamed bowel. Feeding more often and for shorter periods is better than less often and for longer. Formula milk is continued and not diluted.

An electrolyte solution from the pharmacy contains sugar and salts in the proportion in which the bowel absorbs them best. Home-made mixtures and remedies such as cola or diluted juice contain too much sugar and too little salt and can make the diarrhoea worse. With vomiting, small amounts a few minutes apart are more successful than a larger amount at once.

Warning signs of dehydration that should be assessed by a doctor immediately: markedly fewer wet nappies, dark urine, a dry mouth, no tears when crying, a sunken fontanelle or sunken eyes, striking sleepiness, skin folds that stay standing. Likewise blood in the stool and persistent vomiting without diarrhoea.

Agents that stop diarrhoea are not given to infants. The diarrhoea is the way the body gets rid of the organism.

Why the conversation belongs in pregnancy

The first dose is due in the sixth week of life. The first appointment with the paediatrician is usually in the first week of life, the others follow the parent-child pass.

Arithmetically, then, there is time. In practice the sixth week of life is the point at which many families are still occupied with the basics: breastfeeding, sleep, postnatal recovery, applications. A decision about vaccination that surfaces there for the first time gets postponed – and here postponing means something different from usual.

This is why the subject is raised in this practice during antenatal care, usually in the third trimester, together with the dTpa vaccination and the question of finding a paediatrician.

Two things can be dealt with beforehand and save time pressure later: find a paediatrician and pencil in a first appointment – in Vienna places within the public system are taken early – and go through the vaccination questions of the first six months once in peace, while there still is peace.

If you decide against the vaccination

Vaccinations are voluntary in Austria. A refusal is documented and changes nothing about further care.

Being properly informed includes what it means: the child will with high probability have a rotavirus infection at some point – before the vaccination it affected practically everyone. In most it runs a course that can be managed at home; in some it leads to a hospital stay with an infusion.

And it includes the fact that this decision, unlike others, is final. Anyone who decides against it at six weeks cannot decide in favour of it at a year.

This finality is the reason why an undecided attitude has a different effect here than with other vaccinations. Anyone who hesitates over the six-in-one vaccination and agrees six months later has lost time but nothing more; anyone who hesitates over rotavirus has decided without meaning to. Which is why this point appears on this page several times – not as pressure but so that the decision is a conscious one.

What happens next

The vaccination is given by the paediatrician, and that is also where this conversation takes place. In this practice it is about putting the question on the table in good time – in the third trimester, while there is still peace for it. Arranging an appointment.

An overview of everything due in the first year of life is given by the page immunisation schedule for infants and small children. It shows how the rotavirus appointments fit in with the others – and that there are fewer appointments in total than the number of illnesses would suggest, because almost everything is bundled into combination vaccines.