Rotavirus (vomiting and diarrhoea)

The rotavirus vaccination is the first vaccination in a child's life – it begins in the sixth week of life, before all the others are due. For mothers who have just given birth it is therefore the first decision about vaccination at all, and it falls at a time when there is little capacity for decisions. This page explains what it is about, so that the question is already answered before the birth.

What rotaviruses are

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, and rotaviruses were the commonest reason for admission to hospital because of diarrhoea in this age group.

They are transmitted by the faecal-oral route: via hands, objects, toys, door handles. The virus is extraordinarily infectious – ten virus particles are enough for an infection, while a child who is ill excretes billions of them. It survives on surfaces for days and is insensitive to many common disinfectants.

From this follows something that regularly frustrates parents: hygiene alone does not prevent a rotavirus infection. The illness occurs in countries with very good hygienic conditions almost as often as elsewhere – the difference lies not in the frequency but in the mortality.

How the illness runs

After one to three days it usually starts with vomiting, shortly followed by watery diarrhoea, often ten to twenty times a day, together with fever. The illness typically lasts three to eight days.

What is dangerous is not the diarrhoea itself but the loss of fluid. A newborn consists of a greater proportion of water than an adult and at the same time has far smaller reserves; it can become dehydrated within a few hours. This is exactly why the illness hits infants hardest – and exactly why the vaccination begins so early.

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 or listlessness
• skin folds that stay standing
• blood in the stool or persistent vomiting without diarrhoea

Treatment is with fluid – in mild cases with an electrolyte solution from the pharmacy, in severe cases through an infusion. There is no medicine against the virus; agents that stop diarrhoea are unsuitable for infants.

The vaccination: an oral vaccine from the sixth week

The rotavirus vaccine is not injected but swallowed. It is a live vaccine with attenuated viruses which triggers an immune response in the intestine – precisely where the infection would later take place.

In Austria the vaccination is included in the free childhood immunisation programme and has been offered nationwide since 2007 – Austria was thus one of the first countries in Europe with a general rotavirus immunisation programme. Depending on the vaccine used, two or three doses at intervals of at least four weeks are provided for.

The age limits are unusually strict, and there is a reason for that. The first dose should be given by the twelfth week of life, the whole course by the 24th or 32nd week depending on the vaccine. If the start is missed, the vaccination can no longer be caught up – unlike with practically every other vaccination.

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

The fact that the deadline is so tight has a practical consequence: this decision should be taken before the birth. Six weeks after delivery is not a good time to be dealing with a question about vaccination for the first time – and anyone who puts it off loses the opportunity.

What it coincides with among the other appointments

The rotavirus vaccination is offset in time from the other vaccinations of the first year of life, and that causes confusion. For orientation, the usual sequence in Austria:

The rotavirus doses may be given together with other vaccinations on the same day; no interval is needed. For parents that means fewer appointments, which counts for more in the first months than it sounds.

The exact sequence follows the Austrian immunisation schedule currently in force and is determined by the paediatrician. This overview serves to place the rotavirus vaccination in time – not as a schedule for your own planning.

Intussusception

Because this subject is the commonest worry about the rotavirus vaccination, here it is in detail.

In an intussusception one section of bowel telescopes into the next, like a collapsed telescope. 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 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: it is of the order of one to six additional cases per 100,000 vaccinated children, and it exists 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. The calculation is therefore unambiguous – and it is one of the better documented cases of such a weighing-up at all.

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

What this means for the mother

The rotavirus vaccination is a vaccination of the child, not of the mother – unlike the whooping cough vaccination, which is given in pregnancy and works via the placenta. Protection carried over from the mother against rotaviruses exists only to a limited extent and is not sufficient.

Three points concern the time afterwards directly:

Breastfeeding is possible without restriction, before and after the oral vaccine. No pause has to be observed. Older recommendations not to breastfeed around the vaccination are outdated – the antibodies in the milk do not impair effectiveness to any relevant extent.

The vaccine virus is excreted, above all in the first week after the vaccination, in the stool. 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 – then it should be discussed.

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

Diarrhoea in an infant: what to do at home

Vaccinated children get diarrhoea too – only usually one that can be managed at home. Because the question will almost certainly come up in the first months, here are the essentials.

Keep breastfeeding. That is the most important measure and is frequently got wrong. Breast milk contains fluid, salts and nutrients in exactly the right composition, and it 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 likewise continued and not diluted – a diluted bottle supplies less of what is missing.

Electrolyte solution from the pharmacy. It contains sugar and salts in the proportion in which the bowel absorbs them best – the sugar here is not an additive but what makes the transport of salt possible at all. 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.

By the spoonful and often. With vomiting, small amounts a few minutes apart are more successful than a larger amount at once. A syringe without a needle or a spoon works better for this than a bottle.

Observe rather than count. How often the stool comes says less than the number of wet nappies, the child's alertness and the colour of the urine. A child that drinks, responds and has regular wet nappies is on a good path – even with frequent diarrhoea.

Agents that stop diarrhoea are not given to infants. The diarrhoea is the way the body gets rid of the organism; suppressing it moves the problem inwards.

Why an oral vaccine

Rotaviruses attack the lining of the small intestine. The protection needed there arises best when the immune response is triggered there as well – which is why the vaccine is swallowed and not injected.

For parents this has a pleasant side effect: it is the only vaccination in the first year of life without a needle. It is usually given together with the other vaccination appointments, and the child receives it from a small applicator into the pouch of the cheek.

A word about its worldwide significance, because that explains the scale. In countries with good access to medical care, this vaccination is about hospital admissions avoided and about parents not having to drive to an emergency department at night with a dehydrating child. In countries without that access it is about lives: rotaviruses were long one of the commonest causes of death in small children there. Since immunisation programmes were introduced, that number has fallen worldwide by several hundred thousand a year.

How effective the vaccination is

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

Protection lasts through the first years of life, in which the risk is highest. Infections contracted later run a milder course anyway, because the child is bigger and has more reserves. A booster at nursery or school age is therefore not provided for and would make no sense either: the period in which the illness is really dangerous already lies behind the child by then.

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

Other causes of diarrhoea in infancy

The vaccination protects against rotaviruses, not against diarrhoea in general. Because this regularly leads to disappointment, here are the other common organisms and how they can be told apart – though in the individual case only the laboratory can make the distinction.

Noroviruses are the commonest trigger in older children and adults and are behind most outbreaks in nurseries and care homes. The course is violent but short – usually one to two days, with vomiting to the fore. There is no vaccination.

Adenoviruses cause longer, less violent diarrhoea, often together with signs of a cold or conjunctivitis.

Bacterial organisms such as salmonella and campylobacter occur less often in infancy but run a more severe course. Blood or mucus in the stool, high fever and marked abdominal pain point to them and should be investigated.

In practice this means: the question “rotavirus or something else?” changes almost nothing about what is done at home. The fluid intake is the same for all of them, and the warning signs are the same. Only when there is blood in the stool, when the fever stays high or when the child no longer drinks does identifying the organism become important.

When the vaccination is not given

• with a severe immune deficiency in the child
• with a known malformation of the digestive tract that favours intussusception
• with a history of intussusception
• with an acute, severe febrile illness – then it is postponed, not cancelled

A mild infection without fever is no obstacle. Because of the tight age limits, postponement here has greater consequences than with other vaccinations and is handled correspondingly cautiously.

A preterm birth does not exclude the vaccination. The calculation follows actual age and not corrected age – a child born eight weeks early therefore also gets its first dose from the sixth week of life. The reason is the same as elsewhere: it is precisely children born too early who fall particularly severely ill, and the window does not wait.

What happens next

The rotavirus vaccination is given by the paediatrician, usually together with the first examination in the parent-child pass after the birth. In this practice it is a subject of antenatal care: so that the decision does not fall into the first weeks with a newborn, it belongs on the table beforehand.

Two things can be dealt with before the birth and save time pressure later. First: find a paediatrician and pencil in a first appointment – in Vienna places within the public system are taken early, and the first examination is due in the first week of life. Second: go through the vaccination questions of the first six months once in peace, while there still is peace. Both are unspectacular and make a considerable difference to the first weeks.

Arranging an appointment. Which vaccinations are provided for you yourself in pregnancy is set out under whooping cough; which should be completed before a pregnancy, under rubella.