Epidemiology of intussusception among infants in Ethiopia, 2013-2016.

INTRODUCTION: intussusception is a condition in which one segment of the bowel prolapses into another causing obstruction. Information on the epidemiology of intussusception in sub-Saharan Africa is limited. We describe the sociodemographic and clinical characteristics of children with intussusception in Ethiopia. METHODS: active surveillance for children < 12 months of age with intussusception was conducted at six sentinel hospitals in Ethiopia. Limited socio-economic and clinical data were collected from enrolled children. Characteristics among children who died and children who survived were compared using the Wilcoxon rank sum test for continuous variables and Chi-square tests for categorical variables. RESULTS: total of 164 children < 12 months of age with intussusception were enrolled; 62% were male. The median age at symptom onset was 6 months with only 12 (7%) of cases occurring in the first 3 months of life. Intussusception was reduced by surgery in 90% of cases and 10% were reduced by enema; 13% of cases died. Compared to survivors, children who died had a significantly longer time to presentation to the first health care facility and to the treating health care facility (median 3 days versus 2 days, p = 0.02, respectively). CONCLUSION: the high mortality rate, late presentation of intussusception cases, and lack of modalities for non-surgical management at some facilities highlight the need for better management of intussusception cases in Ethiopia.

Intussusception among infants in Tanzania: findings from prospective hospital-based surveillance, 2013-2016.

INTRODUCTION: intussusception surveillance was initiated in Tanzania in 2013 after monovalent rotavirus vaccine was introduced, as part of the 7-country African evaluation to assess whether the vaccine was associated with an increased risk of intussusception. An increased risk from vaccine was not identified. Published data on intussusception in Tanzanian infants are limited. METHODS: prospective intussusception surveillance was conducted at 7 referral hospitals during 2013-2016 to identify all infants with intussusception meeting Brighton Level 1 criteria. Demographic, household and clinical data were collected by hospital clinicians and analyzed. RESULTS: a total of 207 intussusception cases were identified. The median age of cases was 5.8 months and nearly three-quarters were aged 4-7 months. Median number of days from symptom onset to admission at treatment hospital was 3 (IQR 2-5). Seventy-eight percent (152/195) of cases had been admitted at another hospital before transfer to the treating hospital. Enema reduction was not available; all infants were treated surgically and 55% (114/207) had intestinal resection. The overall case-fatality rate was 30% (62/206). Compared with infants who survived, those who died had longer duration of symptoms before admission to treatment hospital (median 4 vs 3 days; p < 0.01), higher rate of intestinal resection (81% [60/82] vs 44% [64/144], p < 0.001), and from families with lower incomes (i.e., less likely to own a television [p < 0.01] and refrigerator [p < 0.05). CONCLUSION: Tanzanian infants who develop intussusception have a high case-fatality rate. Raising the index of suspicion among healthcare providers, allocating resources to allow wider availability of abdominal ultrasound for earlier diagnosis, and training teams in ultrasound-guided enema reduction techniques used in other African countries could reduce the fatality rate.

Acute intestinal intussusception among children under five years of age admitted in an Ouagadougou hospital, Burkina Faso, 2008-2013: epidemiological, clinical and therapeutic aspects.

INTRODUCTION: acute intestinal intussusception is a life-threatening surgical condition. In some settings, rotavirus vaccines have been associated with a low-level increased risk of intussusception. We describe the epidemiology, clinical manifestations and management of intussusception in a tertiary referral hospital in Burkina Faso prior to the introduction of rotavirus vaccine in October 2013. METHODS: we retrospectively reviewed medical records of all children under 5 years of age treated at the Charles de Gaulle Pediatric Hospital for intussusception meeting the Brighton level 1 diagnostic criteria, from October 31st, 2008 to October 30th, 2013. We report the incidence of intussusception as well as descriptive characteristics of these cases. RESULTS: a total of 107 Brighton level 1 intussusception cases were identified, representing a hospital incidence of 21.4 cases / year. There were 69 males and 38 females (sex ratio of 1.8), with a median age of 8 months (range 2 months to 4 years). Sixty-two percent of intussusception cases occurred among infants (n = 67 cases). The average time from symptom onset to seeking medical consultation was 3.8 days +/- 2.7 (range 0 to 14 days). Treatment was mainly surgical (105 patients, 98.1%) with 35 patients (32.7%) undergoing intestinal resection. Thirty-seven patients (35.5%) experienced post-operative complications. The mortality rate was 9.3%. Intestinal resection was a risk factor for death from intussusception. CONCLUSION: in this review of intussusception hospitalizations prior to rotavirus vaccine introduction in Burkina Faso, delays in seeking care were common and were associated with mortality.

Age distribution and mortality associated with intussusception in children under two years of age in nine sentinel surveillance hospitals in Zambia, 2007-2018.

INTRODUCTION: recipients of monovalent rotavirus vaccine have a low risk of developing intussusception (IS) in high- to medium-high-income countries. In sub-Saharan Africa, Zambia included, this risk of IS has not been assessed. Two-dose monovalent rotavirus vaccine, introduced in Zambia in 2012 in the capital of Lusaka, and rolled out countrywide in 2013, is administered at 6 and 10 weeks of age with no catch-up dose. Active IS surveillance monitoring in children < 2 years has been ongoing in Zambia since July 2009 and additional retrospective review was conducted from 2007- June 2009. METHODS: retrospective review (January 2007-June 2009) and prospective (July 2009-December 2018) IS surveillance was conducted at nine hospitals and four large paediatric hospital departments in Zambia, respectively. Demographic and clinical data were collected from medical folder abstraction and supplemented by parental interview during prospective surveillance. RESULTS: a total of 248 children < 2 years with IS were identified; 57.3% were male. Most cases with IS were infants (85.5%). IS admissions remained stable during the surveillance period with no seasonality pattern although an increase in cases occurred between August and October, hot dry season. The median time from symptom onset to presentation for treatment was 2 days and 63.6% (154/242) of IS diagnoses were made during surgery. The bowel resection rate was 46.6%. A high CFR of 23.3% was observed. CONCLUSION: the number of intussusception cases in Zambia was relatively small and remained stable over the 12-year study period. However, a high CFR was observed among cases.

Geospatial distribution of severe paediatric intussusception in KwaZulu-Natal province, South Africa.

INTRODUCTION: intussusception in South African (SA) children is often severe. A proportion of cases require management at quaternary hospitals which are a scare resource in SA. A geospatial investigation of severe paediatric intussusception (SPI) in the KwaZulu-Natal (KZN) province of SA would assist with identifying regions which should be targeted for preventative interventions. This could reduce resource utilisation for this condition at quaternary hospitals. The objective of this study was to determine the geospatial distribution of SPI in KZN. METHODS: this was a retrospective analysis of data for patients with SPI who were admitted to a quaternary hospital in KZN over an 11-year period. Data related to patient demographics, duration of hospitalization, surgical intervention, inpatient mortality and residential postal code were extracted from the electronic hospital admissions system. Each residential postal code was linked to a corresponding KZN district municipality. Descriptive statistical methods were used to determine the distribution of various characteristics in the study sample. Semi-quantitative geospatial analysis was used to determine the distribution of patients with SPI in each KZN district municipality. RESULTS: the study sample consisted of 182 patients with SPI. Most patients were <1 year old (83.5%), male (51.1%) and black African (87.9%). All patients underwent surgical intervention. Inpatient mortality was 2.7%. The majority of patients in the study sample resided in the eThekwini and King Cetshwayo district municipalities (51.1% and 14.8%, respectively). CONCLUSION: preventative interventions for SPI should be considered for rollout in the eThekwini and King Cetshwayo district municipalities of KZN, SA.

Indications, Types and Outcomes of Resections for Acquired Intestinal Conditions in Children.

BACKGROUND: Variable intestinal segments of children may need resection due to congenital or acquired conditions. Resection is done when these intestinal segments are nonviable or dysfunctional. In HICs most resections are for congenital conditions while in LMICs acquired and largely preventable conditions predominate.The spectrum of acquired intestinal conditions leading to bowel resection may also vary between HICs and LMICs. OBJECTIVES: To determine the indications, types and outcomes of intestinal resection for acquired conditions in children. METHODS: A retrospective review of pediatric bowel resections from acquired anomalies over a 10-year period in a tertiary hospital. Data entry and analysis done using SPSS. Fisher's exact test was used to assess level of significance for categorical variables and p-value of <0.05 was adjudged significant. Results are presented as means±SD, ratios, percentages and tables. RESULTS: Fifty-nine males and thirty-three females with a median age of 8 months were recruited. Complicated intussusceptions and right hemicolectomy were the most common indication and procedure respectively. Proportion of right hemicolectomies was more in infants than older children (p=0.0103) while ileal resection was higher in older children (p<0.001). Post-operative complications were seen in 35.8% and mortality rate was 8.7%. CONCLUSION: Complicated intussusception is the main acquired indication for intestinal resection. Right hemicolectomies and ileal resections were done mainly during infancy and beyond infancy respectively.

Pediatric intussusception in Uganda: differences in management and outcomes with high-income countries.

PURPOSE: In high-income countries the presentation and treatment of intussusception is relatively rapid, and most cases are correctable with radiographically-guided reduction. In low-income countries, many delays affect outcomes and surgical intervention is required. This study characterizes the burden and outcome of pediatric intussusception in Uganda. METHODS: Prospective case series of intussusception cases from May 2015 to July 2016 at a tertiary referral hospital in Uganda. RESULTS: Forty patients were included in the study. Male to female ratio was 3:2. Average duration of symptoms before presentation was 4.5 days. Median duration of symptoms in referred patients was 4 days and 2 days in non-referred patients (P value 0.0009). All 40 patients underwent surgical treatment: 25% had resection and enterostomy, 15% had resection and primary anastomosis, 2.5% had resection, primary anastomosis and enterostomy and 57.5% underwent manual reduction. Mortality was 32% and febrile patients on admission were 20 times more likely to die (P value 0.040). CONCLUSION: Intussusception carries a high operative and mortality rate in Uganda. Referred patients presented later than non-referred patients to health facilities. Fever on examination at admission was positively associated with mortality. This disease remains a target for quality metrics in global pediatric surgery. TYPE OF STUDY: Diagnostic study. LEVEL OF EVIDENCE: III.

Risk Factors Associated With Increased Mortality From Intussusception in African Infants.

OBJECTIVES: Morbidity and mortality from intussusception, the leading cause of bowel obstruction in infants, is higher in Africa than in other regions of the world, but the reasons have not been well examined. We sought to identify risk and protective factors associated with death or intestinal resection following intussusception. METHODS: Infants with intussusception from 7 sub-Saharan African countries (Ethiopia, Ghana, Kenya, Malawi, Tanzania, Zambia, and Zimbabwe) were enrolled through active, hospital-based surveillance from February 2012 to December 2016. We examined demographic, clinical, and socioeconomic factors associated with death or intestinal resection following intussusception, using multivariable logistic regression. RESULTS: A total of 1017 infants <1 year of age with intussusception were enrolled. Overall, 13% of children (133/1017) died during the hospitalization, and 48% (467/966) required intestinal resection. In multivariable analyses, female sex [odds ratio (OR) 1.8, 95% confidence interval (CI) 1.2-3.3], longer duration of symptoms before presentation (OR 1.1; 95% CI 1.0-1.2), and undergoing intestinal resection (OR 3.4; 95% CI 1.9-6.1) were associated with death after intussusception. Diagnosis by ultrasound or enema (OR 0.4; 95% CI 0.3-0.7), and employment of a household member (OR 0.7; 95% CI 0.4-1.0) were protective against intestinal resection. CONCLUSIONS: Delays in hospital presentation and female sex were significantly associated with death, whereas higher socioeconomic status and availability of radiologic diagnosis reduced likelihood of undergoing resection. Efforts should be intensified to improve the awareness, diagnosis, and management of intussusception in sub-Saharan African countries to reduce morbidity and mortality from intussusception in these resource-limited settings.

Update on the global epidemiology of intussusception: a systematic review of incidence rates, age distributions and case-fatality ratios among children aged <5 years, before the introduction of rotavirus vaccination.

BACKGROUND: In some countries that have introduced oral rotavirus vaccines, a small but elevated risk of intussusception-a rare bowel disorder-has been reported. Updated estimates on the global epidemiology of intussusception are needed to help predict the potential number of intussusception cases that could be caused by the vaccine in different settings. METHODS: We estimated incidence rates, age distributions and case-fatality ratios (CFRs) for intussusception hospital admissions among children aged <5 years, before the introduction of rotavirus vaccines. We included all articles identified in a systematic review between January 2002 and January 2018, and contacted authors for more granular unpublished data on age distributions. RESULTS: We identified 128 articles containing 227 country datasets (61 age distributions, 71 incidence rates and 95 CFRs). The median age of intussusception ranged from 29 weeks in Africa (83% of cases in the first year of life) to 70 weeks in the Western Pacific region (35% of cases in the first year of life). The median (range) annual incidence of intussusception hospital admissions per 100 000 aged <1 year ranged from 34 (13-56) in Africa to 90 (9-380) in the Western Pacific region. We found extreme differences between the CFRs in Africa (1 death in every 10 hospital admissions) and the rest of the world (fewer than 1 death in every 100-2000 hospital admissions). CONCLUSION: Intussusception epidemiology varies by country and region. Understanding and recognizing these differences will be important when assessing the potential number of intussusception cases associated with rotavirus vaccines.

Preparing for safety monitoring after rotavirus vaccine introduction - Assessment of baseline epidemiology of intussusception among children <2 years of age in four Asian countries.

Intussusception is the invagination of one segment of the bowel into a distal segment, characterized by symptoms of bloody stool, vomiting, and abdominal pain. Previous studies have found regional differences in incidence but the etiology of most intussusception cases is unknown. Rotavirus vaccines were associated with a slightly of increased risk of intussusception in post-licensure evaluations in high- and middle-income countries, but not in low income African countries. To describe the baseline epidemiology of intussusception in young children prior to rotavirus vaccine implementation, active sentinel hospital surveillance for intussusception in children < 2 years of age was conducted in 4 low income Asian countries (Bangladesh, Nepal, Pakistan and Vietnam). Over a 24-month period, 15 sites enrolled 1,415 intussusception cases, of which 70% were enrolled in Vietnam. Overall, 61% of cases were male and 1% (n = 16) died, ranging from 8% in Pakistan to 0% in Vietnam. The median age of cases enrolled ranged from 6 months in Bangladesh and Pakistan to 12 months in Vietnam. The proportion of cases receiving surgical management was 100% in Bangladesh, 88% in Pakistan, 61% in Nepal, and 1% in Vietnam. The high proportion of males and median age of cases around 6 months of age found in this regional surveillance network are consistent with previous descriptions of the epidemiology of intussusception in these countries and elsewhere. Differences in management and the fatality rate of cases between the countries likely reflect differences in access to healthcare and availability of diagnostic modalities. These baseline data will be useful for post-rotavirus vaccine introduction safety monitoring.

Evaluation of Intussusception after Monovalent Rotavirus Vaccination in Africa.

BACKGROUND: Postlicensure evaluations have identified an association between rotavirus vaccination and intussusception in several high- and middle-income countries. We assessed the association between monovalent human rotavirus vaccine and intussusception in lower-income sub-Saharan African countries. METHODS: Using active surveillance, we enrolled patients from seven countries (Ethiopia, Ghana, Kenya, Malawi, Tanzania, Zambia, and Zimbabwe) who had intussusception that met international (Brighton Collaboration level 1) criteria. Rotavirus vaccination status was confirmed by review of the vaccine card or clinic records. The risk of intussusception within 1 to 7 days and 8 to 21 days after vaccination among infants 28 to 245 days of age was assessed by means of the self-controlled case-series method. RESULTS: Data on 717 infants who had intussusception and confirmed vaccination status were analyzed. One case occurred in the 1 to 7 days after dose 1, and 6 cases occurred in the 8 to 21 days after dose 1. Five cases and 16 cases occurred in the 1 to 7 days and 8 to 21 days, respectively, after dose 2. The risk of intussusception in the 1 to 7 days after dose 1 was not higher than the background risk of intussusception (relative incidence [i.e., the incidence during the risk window vs. all other times], 0.25; 95% confidence interval [CI], <0.001 to 1.16); findings were similar for the 1 to 7 days after dose 2 (relative incidence, 0.76; 95% CI, 0.16 to 1.87). In addition, the risk of intussusception in the 8 to 21 days or 1 to 21 days after either dose was not found to be higher than the background risk. CONCLUSIONS: The risk of intussusception after administration of monovalent human rotavirus vaccine was not higher than the background risk of intussusception in seven lower-income sub-Saharan African countries. (Funded by the GAVI Alliance through the CDC Foundation.).

Review of Naturally Occurring Intussusception in Young Children in the WHO African Region prior to the Era of Rotavirus Vaccine Utilization in the Expanded Programme of Immunization.

Rotavirus vaccines, Rotarix and RotaTeq, are increasingly being introduced in national immunization programmes in Africa to prevent severe dehydrating acute gastroenteritis. A low-level risk of intussusception has been associated with rotavirus vaccines. We reviewed published data on intussusception in children <2 years of age in Africa. PubMed electronic database search was used to retrieve papers published on intussusception. The search was further refined to identify surveillance reports and case series conducted from 1980 to 2014, with at least 25 cases. The initial search identified 34 studies, and the refined search yielded 16. Intussusception occurred naturally in infants 2-4 months and peaked around 5-8 months of age. Delayed presentation was common and required surgical intervention in 87% (1008 of 1158) of cases with a high CFR, 10-33.7%. In African children, intussusception has been reported infrequently at a young age when the first dose of rotavirus vaccine is administered.

Intussusception Cases Among Children Admitted to Referral Hospitals in Kenya, 2002-2013: Implications for Monitoring Postlicensure Safety of Rotavirus Vaccines in Africa.

To describe the epidemiology of intussusception before introduction of the rotavirus vaccine, we reviewed the records of 280 patients younger than 5 years who were hospitalized in Kenya between 2002 and 2013. The patients who died (18 [6.4%]) had sought care later after symptom onset than the patients who survived (median, 5 vs 3 days, respectively; P = .04). Seeking prompt care may improve therapeutic outcomes.

Intussusception in infants--storm from a clear sky.

Intussusception is one of the most common causes of acute abdominal conditions requiring surgical therapy in infants and babies. Due to the breakthroughs of pediatric intensive care and imaging methods, which may sometimes replace therapeutic methods, this condition, which used to be associated with high morbidity and mortality rates, is now more easily detected and treated immediately, even by non-surgical means. Nevertheless, there still is a high percent of cases in whom the diagnosis is set relatively late and who require laborious surgical procedures and extensive intestinal resections. These cases have high morbidity rates, the condition sometimes has a negative course and the patients die. We conducted an analytical retrospective study on a group of 49 patients diagnosed with intussusceptions, hospitalized and treated in the Pediatric Surgery Ward of the Children's Hospital of Iasi City during 5 years. Although the demographics and clinical presentation of our patients is largely in agreement with literature data, we note that 69.4% of the patients came to the hospital 24 hours after the onset of their symptoms, which delayed diagnosis setting, ruled out non-surgical therapy and thus led to a high rate of postoperative complications (24.5%) and also to a high mortality rate (6.6%).

The effectiveness of a rotavirus vaccine in preventing hospitalizations and deaths presumably due to acute infectious diarrhea in Brazilian children: a quasi-experimental study.

INTRODUCTION: Rotavirus is the main etiologic agent of acute infectious diarrhea in children worldwide. Considering that a rotavirus vaccine (G1P8, strain RIX4414) was added to the Brazilian vaccination schedule in 2006, we aimed to study its effectiveness and safety regarding intestinal intussusception. METHODS: A quasi-experimental trial was performed in which the primary outcome was the number of hospitalizations that were presumably due to acute infectious diarrhea per 100,000 children at risk (0-4 years old). The secondary outcomes included mortality due to acute infectious diarrhea and the intestinal intussusception rates in children in the same age range. We analyzed three scenarios: Health Division XIII of the State of São Paulo (DRS XIII) from 2002 to 2008, the State of São Paulo, and Brazil from 2002 to 2012. RESULTS: The averages of the hospitalization rates for 100,000 children in the pre- and post-vaccination periods were 1,413 and 959, respectively, for DRS XIII (RR=0.67), 312 and 249, respectively, for the State of São Paulo (RR=0.79), and 718 and 576, respectively, for Brazil (RR=0.8). The mortality rate per 100,000 children in the pre- and post-vaccination periods was 2.0 and 1.3, respectively, for DRS XIII (RR=0.66), 5.5 and 2.5, respectively, for the State of São Paulo (RR=0.47), and 15.0 and 8.0, respectively, for Brazil (RR=0.53). The average annual rates of intussusception for 100,000 children in DRS XIII were 28.0 and 22.0 (RR=0.77) in the pre- and post-vaccination periods, respectively. CONCLUSIONS: A monovalent rotavirus vaccine was demonstrated to be effective in preventing the hospitalizations and deaths of children that were presumably due to acute infectious diarrhea, without increasing the risk of intestinal intussusception.

The effectiveness of a rotavirus vaccine in preventing hospitalizations and deaths presumably due to acute infectious diarrhea in Brazilian children: a quasi-experimental study

INTRODUCTION: Rotavirus is the main etiologic agent of acute infectious diarrhea in children worldwide. Considering that a rotavirus vaccine (G1P8, strain RIX4414) was added to the Brazilian vaccination schedule in 2006, we aimed to study its effectiveness and safety regarding intestinal intussusception. METHODS: A quasi-experimental trial was performed in which the primary outcome was the number of hospitalizations that were presumably due to acute infectious diarrhea per 100,000 children at risk (0-4 years old). The secondary outcomes included mortality due to acute infectious diarrhea and the intestinal intussusception rates in children in the same age range. We analyzed three scenarios: Health Division XIII of the State of São Paulo (DRS XIII) from 2002 to 2008, the State of São Paulo, and Brazil from 2002 to 2012. RESULTS: The averages of the hospitalization rates for 100,000 children in the pre- and post-vaccination periods were 1,413 and 959, respectively, for DRS XIII (RR=0.67), 312 and 249, respectively, for the State of São Paulo (RR=0.79), and 718 and 576, respectively, for Brazil (RR=0.8). The mortality rate per 100,000 children in the pre- and post-vaccination periods was 2.0 and 1.3, respectively, for DRS XIII (RR=0.66), 5.5 and 2.5, respectively, for the State of São Paulo (RR=0.47), and 15.0 and 8.0, respectively, for Brazil (RR=0.53). The average annual rates of intussusception for 100,000 children in DRS XIII were 28.0 and 22.0 (RR=0.77) in the pre- and post-vaccination periods, respectively. CONCLUSIONS: A monovalent rotavirus vaccine was demonstrated to be effective in preventing the hospitalizations and deaths of children that were presumably due to acute infectious diarrhea, without increasing the risk of intestinal intussusception. .

Intussusception incidence rates in 9 Zambian hospitals, 2007-2011: prerotavirus vaccine introduction.

BACKGROUND: Intussusception, a rare adverse event associated with rotavirus vaccines in some settings, is a common cause of intestinal obstruction in infants and toddlers globally with a peak age of 4-6 months. This age group may overlap with the extended age of administering rotavirus vaccine. METHODS: A retrospective (January 2007 to June 2009) and prospective (July 2009 to June 2012) survey was conducted in 9 Zambian hospitals. Children between 0 and 24 months who were operated on for intestinal obstruction/intussusception were identified in theatre log books. In the latter part of the survey, patients were recruited prospectively. Demographic, clinical and surgical data from hospital files were collected for each patient. RESULTS: One-hundred and five children were identified to have undergone surgery for intussusceptions. Many were boys 57.6% (57/99). Of those with complete data, intussusception was common in infants 86.9% (86/99) and many children (68.0%) were between 3 and 8 months of age with a peak age of 5-6 months. Lusaka had the highest number of children with intussusception with an estimated annual incidence rate of 12/100,000 in children <2 years of age. The overall case fatality rate was very high 33.7% (31/92). CONCLUSION: Intussusception was common in infants with a peak age of 5-6 months, and of particular concern is the group of 2-4 months the age of rotavirus vaccination. The estimated incidence rate of 12/100,000 is an underestimate as many cases may not present for care. The high case fatality rate of 33.7% is due to both delayed presentation and diagnosis in hospital.

Adult intussusception: diagnostic pitfalls, morbidity and mortality in a developing country.

OBJECTIVE: To study diagnostic pitfalls, morbidity and mortality of adult intussusception. PATIENTS AND METHODS: Retrospective study of adult patients records operated between 1979 and 2007 with the diagnosis of adult intussusception. RESULTS: We found 41 cases of adult intussusception. The mean age was 35.2 years (standard deviation (SD)=7.1). The delay between onset and medical consultation was 15 days. The diagnosis was made pre-operatively in 11 cases. Abdominal ultrasound showed an abdominal mass in 11 cases. Ileo-ileal intussusception was most frequent (16 cases). Intussusception was secondary in 24 cases. There were seven instances of intestinal necrosis. Intestinal resection was performed in 34 cases. Surgical site infection occurred in four patients, three patients died. CONCLUSION: The pre-operative diagnosis of acute intestinal intussusception is difficult. Morbidity and mortality rates are high. Improved diagnostic investigations in developing countries could improve the prognosis of this condition.

Potential intussusception risk versus health benefits from rotavirus vaccination in Latin America.

BACKGROUND: With the recent postlicensure identification of an increased risk of intussusception with rotavirus vaccine, the 14 Latin American countries currently using rotavirus vaccine must now weigh the health benefits versus risks to assess whether to continue vaccination. To inform policy considerations, we estimated excess intussusception cases and mortality potentially caused by rotavirus vaccine for each of the 14 countries and compared these estimates to hospitalizations and deaths expected to be averted through vaccination. METHODS: We used regional rotavirus disease burden and rotavirus vaccine efficacy data, global natural intussusception and regional rotavirus vaccine-related risk estimates, and country-specific diphtheria, tetanus, and pertussus vaccination coverage rates to estimate rotavirus vaccine coverage rates. We performed a probabilistic sensitivity analysis to account for uncertainty in these parameters. RESULTS: For an aggregate hypothetical birth cohort of 9.5 million infants in these 14 countries, rotavirus vaccine would annually prevent 144 746 (90% confidence interval [CI], 128 821-156 707) hospitalizations and 4124 deaths (90% CI, 3740-4239) due to rotavirus in their first 5 years of life but could cause an additional 172 hospitalizations (90% CI, 126-293) and 10 deaths (90% CI, 6-17) due to intussusception, yielding benefit-risk ratios for hospitalization and death of 841:1 (90% CI, 479:1 to 1142:1) and 395:1 (90% CI, 207:1 to 526:1), respectively. In an uncertainty analysis using 10 000 simulations of our probabilistic parameters, in comparing rotavirus disease averted to intussusception events caused, the hospitalization ratio was never below 100:1, and our death ratio fell below 100:1 only once. CONCLUSIONS: The health benefits of vaccination far outweigh the short-term risks and support continued rotavirus vaccination in Latin America.

Trends in intussusception-associated deaths among US infants from 1979-2007.

OBJECTIVE: We examined data from 1979-2007 to generate up-to-date baseline estimates of rotavirus intussusception mortality in US infants, to inform policy deliberations of the risks and benefits of vaccination. STUDY DESIGN: Secular trends in the infant intussusception mortality rate were evaluated using national multiple cause-of-death and natality data from 1979- 2007. Linked birth/infant death data from 1998-2006 were examined to identify risk factors for intussusception deaths. RESULTS: After declining from 1979-1996, the average annual intussusception mortality rate stabilized from 1997-2007 at 2.1 per 1 million live births (range, 1.0-3.0). In multivariate analysis, significant variables associated with intussusception deaths included no prenatal care (OR, 5.4; 95% CI, 1.9-15.4) and birth order (≥3rd) (OR, 2.4; 95% CI, 1.4-4.4 [reference: birth order (1st)]). CONCLUSIONS: Given the annual variation in intussusceptions mortality and low baseline rates, if a low vaccine-associated risk of death from intussusception exists in the United States, it would be difficult to assess using intussusception mortality trend data alone. Factors associated with intussusception mortality risk may be related to delayed or reduced health care access.