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Rotavirus vaccine coverage continues to lag behind that of other pediatric vaccines on the same recommended schedule, such as diphtheria, tetanus, and pertussis (DTaP), and behind public health goals, according to an analysis of New Vaccine Surveillance Network (NVSN) data.

National Immunization Survey-Child data for births from 2013 to 2021 (the last years data are available) estimate 94% coverage for at least three doses of the DTaP vaccine by age 24 months vs 72%-77% for a completed rotavirus vaccine series by age 8 months. Authors of the new analysis detail why rotavirus vaccine coverage is challenging in the US.

Authors led by Mary C. Moran, PhD, MPH, on behalf of the NVSN Acute Gastroenteritis Working Group of the American Academy of Pediatrics (AAP) said that among the reasons is that the Advisory Committee on Immunization Practices (ACIP) recommends the first dose of rotavirus vaccine be delivered by a maximum age of 14 weeks, 6 days and that the vaccine not be delivered until discharge from the NICU. AAP guidelines, however, state that hospitals may consider administering rotavirus vaccine to otherwise-eligible infants in the NICU. Both groups advise that the rotavirus vaccine series (either two doses or three doses, be completed by 8 months, 0 days.)

Transmission in NICU Is Rare

The recommendation against rotavirus vaccine being given in the NICU was based on “a theoretic risk of vaccine virus transmission,” the authors wrote, but studies have suggested that transmission of the vaccine virus in the NICU is rare and unlikely to cause illness in unvaccinated children.

The researchers reported they found that more than half of the extremely preterm infants never started the rotavirus vaccine series. The ACIP recommendation likely prevents many infants at risk for severe rotavirus disease from getting the vaccine, they stated. More than 50% of extremely preterm children were not discharged from the NICU until at least age 15 weeks, making them ineligible to get the vaccine.

The authors said vaccine guidelines should be changed to allow rotavirus vaccine administration in the NICU to remove barriers to vaccination and help improve rotavirus vaccine coverage.

More Than 24,000 Included in the Study

Children (n = 24,775) born on or after January 1, 2007, enrolled in the New Vaccine Surveillance Network from December 2014 to August 2024 aged at least 15 weeks with rotavirus-negative acute gastroenteritis or as healthy control individuals and with known vaccination status were included in the study.

Rotavirus vaccine coverage significantly differed by gestational age. Compared with term infants, a larger proportion of extremely preterm infants did not receive rotavirus vaccine dose 1 (55% vs 8%) or received it later — at ≥ age 15 weeks (17% vs 3%).

Being extremely preterm was one of the main barriers to receiving vaccine and compared with term infants, they had an odds ratio (OR) of 14.6 for not receiving dose 1 (95% CI, 11.2-20.0). Lack of health insurance was associated with more than twice the odds of not starting the vaccine (OR, 2.2; 95% CI, 1.8-2.7).

“The vaccine age restrictions likely resulted in some infants not receiving RVV [rotavirus vaccine], including some who may be at high risk of severe rotavirus infections,” the authors wrote.

‘A Modern Vaccine Success Story’

The rotavirus vaccine, which has been available for nearly 20 years, “is largely regarded by pediatricians as a modern vaccine success story given its significant impact since its inception,” Ashanti Woods, MD, a pediatrician at Mercy Medical Center in Baltimore, told Medscape Medical News. “Prior to the now widely available vaccine, the rotavirus gastrointestinal illness, characterized by violent vomiting, diarrhea, abdominal pain, and severe dehydration, is believed to have globally claimed the lives of nearly 500,000 children annually and to have affected millions more, many needing treatment in a hospital setting.” He noted that rotavirus vaccine has been credited with reducing the annual global mortality number to between 100,000 and 150,000 deaths a year and has made mortality from rotavirus in the US “exceedingly rare.”

Woods said it’s time to investigate whether rotavirus vaccine can be safely administered to infants 15 weeks or older, continued beyond 8 months of age to complete the series, and administered in the NICU “to see if this effective vaccine can be administered to children who otherwise may be susceptible to a preventable illness.”

AAP Strongly Recommends the Vaccine for All Infants

In an accompanying editorial, Jessica R. Cataldi, MD, MSCS, and Sean T. O’Leary, MD, MPH, with the Department of Pediatrics, University of Colorado School of Medicine in Aurora, Colorado, pointed out that studies from several countries have shown the safety of rotavirus vaccination in NICUs, including a large study from the Children’s Hospital of Philadelphia, Philadelphia, “that found < 1% of stool samples from patients who were unvaccinated tested positive for vaccine-strain rotavirus.”

Among unvaccinated infants who tested positive in that study, “none had gastrointestinal symptoms,” they wrote. Those studies support Moran’s team’s suggestion that guidance for rotavirus vaccination in NICUs may be too restrictive, Cataldi and O’Leary wrote.

The study helps healthcare professionals better understand the barriers to rotavirus vaccination and may help inform policy, the editorialists wrote.

“Regardless of what the federal government does with rotavirus vaccine recommendations, the AAP will continue to recommend rotavirus vaccination for all eligible infants,” they wrote. “NICUs should examine their policies regarding rotavirus vaccine, and pediatricians should continue to offer a strong recommendation for this very safe, highly effective vaccine to all infants.”

Moran reported having no relevant financial relationships. Disclosures for other study authors are available with the full paper. The editorialists, Cataldi and O’Leary, and Woods also reported having no relevant financial relationships.

Marcia Frellick is a Chicago-based healthcare journalist and a regular contributor to Medscape.