The Rotavirus Vaccine Story: From Discovery to the Eventual Control of Rotavirus Disease.

Worldwide, rotavirus is the leading pathogen causing severe diarrhea in children and a major cause of under 5 years mortality. In 1998, the first rotavirus vaccine, RotaShield, was licensed in the United States but a rare adverse event, intussusception, led to its withdrawal. Seven years passed before the next generation of vaccines became available, Rotarix (GSK) and Rotateq (Merck), and 11 years later, 2 additional vaccines from India, Rotavac (Bharat) and Rotasiil (Serum Institute), were recommended by World Health Organization for all children. Today, these vaccines are used in more than 100 countries and have contributed to marked decreases in hospitalizations and deaths from diarrhea. However, these live oral vaccines are less effective in low-income countries with high under 5 years mortality for reasons that are not understood. Efforts to develop new vaccines that avoid the oral route are in progress and will likely be needed to ultimately control rotavirus disease.

Prevaccination Rotavirus Serum IgG and IgA Are Associated With Lower Immunogenicity of Live, Oral Human Rotavirus Vaccine in South African Infants.

BACKGROUND: Live oral rotavirus (RV) vaccines have shown modest efficacy among children in African countries for reasons that are not completely understood. We examined the possible inhibitory effect of preexisting antirotavirus antibodies on immunogenicity of monovalent RV vaccine (RV1). METHODS: Mother-infant pairs were enrolled at presentation for their routine immunization visit in Soweto, South Africa, when infants were aged 5-8 weeks. Infant serum samples were obtained before the first and second doses of RV1 and 1 month after the second dose. Maternal serum and breast milk samples were obtained prior to administration of each dose of RV1 to infants. RV-specific immunoglobulin G (IgG), IgA, and neutralizing activity in sera of infants and serum or breast milk samples of mothers were measured using enzyme-linked immunosorbent assays or a microneutralization test. RESULTS: Of the 107 serum pairs from infants who were seronegative for RV IgA at enrollment, we observed a strong positive association between IgG titers in pre-dose 1 sera of infants and mothers and significant negative associations between IgG titers in pre-dose 1 sera of infants and seroconversion to RV1 post-dose 1. Similarly, mothers whose infants' IgA seroconverted after RV1 had significantly lower pre-dose 1 IgG titers in sera than those whose infants did not seroconvert. CONCLUSIONS: High levels of preexisting serum IgG, including transplacentally acquired maternal IgG, appeared to have an inhibitory effect on the immunogenicity of RV1 among infants and may, in part, contribute to lower efficacy of RV vaccines in this and other low-income settings.

A systematic review of anti-rotavirus serum IgA antibody titer as a potential correlate of rotavirus vaccine efficacy.

BACKGROUND: Identifying an immunological correlate of protection for rotavirus vaccines (Rotarix [RV1] and RotaTeq [RV5]) would substantially facilitate testing of interventions for improving efficacy in developing countries and evaluating additional candidate rotavirus vaccines. METHODS: We accessed PubMed and ClinicalTrials.gov to identify immunogenicity and efficacy trials for RV1 and RV5 to correlate anti-rotavirus serum immunoglobulin A (IgA) antibody titers vs efficacy in regions stratified by all-cause under-5 mortality rates (u5MR). We established a cutoff point for IgA geometric mean concentration or titer (GMC) that predicted lower efficacy and calculated pooled vaccine efficacy among countries with high vs low IgA titers. FINDINGS: We observed an inverse correlation between u5MR and IgA titers for RV1 (r(2) = 0.72; P < .001 and RV5 (r(2) = 0.66; P < .001) and between efficacy and IgA titers for both vaccines (r(2) = 0.56; P = .005). Postimmunization anti-rotavirus IgA GMC <90 were associated with decline in vaccine efficacy. Efficacy during first 2 years of life was significantly lower among countries with IgA GMC < 90 (44%; 95% confidence interval [CI], 30-55) compared to countries with GMC > 90 (85%; 95% CI, 82-88). INTERPRETATION: We observed a significant correlation between IgA titers and rotavirus vaccine efficacy and hypothesize that a critical level of IgA antibody titer is associated with a sufficient level of sustained protection after rotavirus vaccination.

The future control of rotavirus disease: Can live oral vaccines alone solve the rotavirus problem?

Live oral rotavirus (RV) vaccines used worldwide are most effective in reducing diarrheal hospitalizations from RV in high income countries and least effective in low income countries where RV remains a prime cause of death in children. Research has failed to fully explain the reason for this difference of efficacy for RV vaccines, an observation made with other live oral vaccines for polio, cholera and typhoid fever. Use of parenteral vaccines have been successful in overcoming this problem for both polio and typhoid and parenteral RV vaccines are now in development. This approach should be pursued for rotavirus vaccine as well because in low income countries where oral RV vaccines have been introduced and are only partially effective, RV remains the most common cause of diarrhea in children under 5 years. The ultimate control of RV diarrheal will likely require both oral and parenteral vaccines.

Rotavirus and rotavirus vaccines.

Two new rotavirus vaccines have recently been licensed that will provide the intervention needed to diminish the huge burden of rotavirus disease among all children. In many upper and middle income countries, these vaccines will soon be available for the routine immunization of children. The impact should be a rapid and measurable reduction in hospitalizations and doctor visits for acute diarrhea in children, especially in the winter rotavirus season. While few deaths occur in these settings, the illness has consequences in terms of both medical costs and indirect costs, including parents work time lost. In the developing world, clinical trials are still needed to ensure that the vaccines being licensed will work as expected in children living in poor settings. In these settings, other enteric flora, micronutrient malnutrition, higher titers of maternal antibody and other factors still poorly defined have compromised other live oral vaccines and have required the developers to alter vaccine formulation, dose, or schedule. Until these trials are completed, we can only hope that the efficacy will be comparable and that the vaccine will prove to be life-savers. Once the efficacy and safety have been established, rotavirus vaccines could provide a major boost to programs for child survival.

Association of Maternal Immunity with Rotavirus Vaccine Immunogenicity in Zambian Infants.

INTRODUCTION: Live attenuated oral vaccines against rotavirus (RV) have been shown to be less efficacious in children from developing countries. Reasons for this disparity are not fully understood. We assessed the role of maternal factors including breast milk RV-specific IgA, transplacentally acquired infant serum RV-specific IgG and maternal HIV status in seroconversion among Zambian infants routinely immunized with Rotarix™ (RV1). METHODS: 420 mother-child pairs were recruited at infant age 6-12 weeks in Lusaka. Clinical information and samples were collected at baseline and at one month following the second dose of RV1. Determination of breast milk RV-specific IgA and serum RV-specific IgA and IgG was done using standardized ELISA. Seroconversion was defined as a ≥ 4 fold rise in serum IgA titre from baseline to one-month post RV1 dose 2, while seropositivity of IgA was defined as serum titre ≥ 40 and antibody variables were modelled on log-base 2. Logistic regression was used to identify predictors of the odds of seroconversion. RESULTS: Baseline infant seropositivity was 25.5% (91/357). The seroconversion frequency was 60.2% (130/216). Infants who were IgA seropositive at baseline were less likely to seroconvert compared to their seronegative counterparts (P = 0.04). There was no evidence of an association between maternal HIV status and seroconversion (P = 0.25). Higher titres of breast milk rotavirus-specific IgA were associated with a lower frequency of seroconverson (Nonparametric test for trend Z = -2.84; P<0.01): a two-fold increase in breast milk RV-specific IgA titres was associated with a 22% lower odds of seroconversion (OR = 0.80; 95% CI = 0.68-0.94; P = 0.01). There was seasonal variation in baseline breast milk rotavirus-specific IgA titres, with significantly higher GMTs during the cold dry months (P = 0.01). CONCLUSION: Low immunogenicity of RV1 vaccine could be explained in part by exposure to high antibody titres in breast milk and early exposure to wild-type rotavirus infections. Potential interference of anti-RV specific IgA in breast milk and pre-vaccination serum RV specific-IgA and IgG titres with RV1 seroconversion and effectiveness requires further research.

Rotavirus vaccines: successes and challenges.

Since 2006, the availability of two new rotavirus vaccines has raised enthusiasm to consider the eventual control and elimination of severe rotavirus diarrhea through the global use of vaccines. Rotavirus remains the most severe cause of acute diarrhea in children worldwide responsible for several hundred thousands of deaths in low income countries and up to half of hospital admissions for diarrhea around the world. The new vaccines have been recommended by WHO for all infants and in more than 47 countries, their introduction into routine childhood immunization programs has led to a remarkable decline in hospital admissions and even deaths within 3 years of introduction. Challenges remain with issues of vaccine finance globally and the problem that these live oral vaccines perform less well in low income settings where they are needed most. Ongoing research that will accompany vaccine introduction might help address these issues of efficacy and new vaccines and novel financing schemes may both help make these vaccines universally available and affordable in the decade.

Does a monovalent inactivated human rotavirus vaccine induce heterotypic immunity? Evidence from animal studies.

There is substantial evidence for broad cross-reactive immunity and heterotypic protection among human rotavirus strains in children with natural infection or with monovalent Rotarix vaccination. In this commentary, we addressed this same topic by testing sera of guinea pigs and gnotobiotic piglets that were intramuscularly immunized with an inactivated human rotavirus vaccine and also demonstrated a broad cross-protective immunity among human rotavirus strains. Our findings from a single human strain in animal studies bode well for a low cost and efficacious inactivated vaccine to protect children against rotavirus disease throughout the world.

Inactivated rotavirus vaccines: a priority for accelerated vaccine development.

Live oral rotavirus vaccines have proven to be generally safe and effective to prevent severe dehydrating diarrhea among children in high and some middle income countries. However, concerns linger about rare but severe adverse events, such as intussusception and their efficacy against the full range of rotavirus serotypes. More importantly, live oral vaccines have been less immunogenic and results of trials to assess their efficacy in poor children of both Africa and Asia will not be available for 2-3 years. This review describes the rationale for developing an inactivated rotavirus vaccine (IRV) as an alternative approach should live oral vaccines not work well in these challenging populations. Studies have demonstrated the protective role of serum antibody in animals and children and the robust serum antibody response and protection against rotavirus infection in animal models following parenteral immunization with IRV. Four years after licensing the first new generation of rotavirus vaccine, we still remain several years away from knowing how well they work in the target populations. Research to develop alternative approaches should be fostered as an insurance policy to protect against suboptimal efficacy or unanticipated adverse events that could hinder global immunization and protection of all children.

The epidemiology and burden of rotavirus in China: a review of the literature from 1983 to 2005.

We reviewed studies of rotavirus in MEDLINE and the Chinese literature to get a preliminary estimate of the burden of rotavirus gastroenteritis in China and the epidemiology of the disease. Studies were selected if they were conducted for a period 1 year or more, had more than 100 patients enrolled, and used an accepted diagnostic test. Overall, in 27 reports of children hospitalized for diarrhea in urban areas and 3 in rural areas, 44 and 33%, respectively, had rotavirus identified as the etiologic agent. Rotavirus was less commonly detected in children with milder illness seen in clinics (26% in urban and 28% in rural areas) and those cared for in the community (9%). The four main strains of rotavirus in circulation worldwide were also found in China and while G1 was the predominant strain overall, G3 emerged to be the most common strain in 9 of the 12 most recent studies. The disease has a distinct winter seasonal pattern and affects most children in their first 2 years of life. Although further studies are required to fully assess the burden of rotavirus diarrhea before decisions can be made about vaccine use, this review suggests that development and implementation of rotavirus vaccines should be a national priority.