Rotavirus and Red Book 2009: An interview with Larry K. Pickering, MD, editor

I've been around long enough that I have seen all of the vaccine-preventable diseases that are listed in the childhood and adolescent immunization schedule. I'm fortunate in a way because I have that history, which allows a full appreciation of the miraculous decrease that has occurred in the rates of these diseases with the advent of many immunizations. I fully support and follow the childhood and adolescent immunization recommendations of the American Academy of Pediatricians and the CDC Advisory Committee on Immunization Practices.

— Larry K. Pickering, MD

Larry K. Pickering, MD, supports the processes of the Centers for Disease Control and Prevention (CDC) and the American Academy of Pediatrics (AAP) that lead to the recommendations in the Red Book for immunization practices in general and for rotavirus in particular.

The Red Book, a compilation of manifestations, etiology, epidemiology, diagnosis, treatment and prevention of approximately 200 childhood infectious diseases, is updated every 3 years, and the latest edition, edited by Dr. Pickering, includes an overhaul of the chapter on rotavirus.

"The entire rotavirus chapter has been updated," Dr. Pickering said. "The epidemiology and surveillance sections reflect current trends. Specifically, the recommendations for use of the two rotavirus vaccines reflect recommendations of the Committee on Infectious Diseases of the AAP and the Advisory Committee on Immunization Practices [ACIP] from the CDC."

The AAP recommends routine immunization of infants in the United States with rotavirus vaccine, either RV5 (RotaTeq) or RV1 (Rotarix). RV5 was licensed by the FDA in February 2006 and RV1 was licensed in April 2008. Recommendations for administration of these two vaccines have been harmonized.

Larry K. Pickering

"We do not put new vaccine recommendations in the Red Book unless the CDC or the AAP has made recommendations for their use. Information about the two new rotavirus vaccines is in a table in the Red Book, so it is easy to review the differences. The Red Book includes the specific rotavirus vaccine recommendations in 20 bullet points for ease of reference; people can read those 20 bullet points and have a thorough idea of when, how, and to whom the vaccine should be given," Dr. Pickering said.

Current vaccine recommendations, treatment updates, and new chapters and sections are among the major changes in the 2009 Red Book. More tables and figures have been added to make data retrieval easy, Dr. Pickering said, and all the major changes are summarized in the front of the book for quick reference. Recommendations for rotavirus immunization are among the 92 major changes in the 2009 edition.

An enhanced feature from previous editions is inclusion of Web sites that are indexed as well as highlighted in bold throughout the text so more extensive and updated information can be accessed quickly. Updates to the Red Book are ongoing and are posted to the AAP Web site Red Book Online.

2008-2009 Rotavirus season data available

"When a vaccine recommendation for use in every child in this country is made, a good surveillance system to determine what happens is needed," Dr. Pickering said. The CDC has a national passive laboratory surveillance network that monitors temporal and geographic trends for various viral pathogens including rotavirus.

Citing a CDC report in Morbidity and Mortality Weekly Report (Oct. 23, 2009) and recent presentations to the ACIP, Dr. Pickering said that data from the National Respiratory and Enteric Viruses Surveillance System were analyzed and indicated:

1.The 2007-2008 and 2008-2009 rotavirus seasons were shorter and occurred later when compared with 2000 through 2006.

2. The number of positive test results for rotavirus from stool specimens in these surveillance sites during each of these seasons was substantially lower than the median observed in 2000-2006.

Dr. Pickering said that this trend has been observed in surveillance data from two rotavirus seasons, but additional data will be collected to determine if rotavirus vaccine rates increase and the decrease in disease rates continue.

“Even though rotavirus immunizations rates are not near the 90% level we hope to achieve, the reduction in the number of children hospitalized and the number of children with diarrhea due to rotavirus is phenomenal," he said.

Vaccine safety

Rotavirus vaccine is given orally, so safety issues associated with vaccines that are injected, such as pain and redness at the injection site, are not concerns, Dr. Pickering said. Furthermore, data presented at the October 2009 ACIP meeting showed that the two recommended rotavirus vaccines are not associated with intussusception, with Kawasaki disease, or with any other serious adverse event.

"Safety of vaccines is an issue about which people worry " Dr. Pickering said. “It is reassuring that there have been no serious adverse events associated with the current rotavirus vaccines. The surveillance systems will continue to monitor the safety of the rotavirus vaccines.”

As the safety of vaccines is proven, the timing of dosing may be eased a bit. "Coming down the pipeline, we might see a little tweaking of the schedule of administration if data support a change," Dr. Pickering said. "Physicians have done a great job in adhering to the current rotavirus vaccine schedule," he said.

Vigilance is key, though, to maintaining the excellent results that have been achieved thus far in the recommended childhood and adolescent immunization program. As incidence and severity of rotavirus infection decrease, the concern is that some parents may begin to think the vaccine is not needed because the disease rates are low.

"We don't see the diseases now to show parents and young physicians what happened before vaccines became available. So as the diseases go away, people worry more about adverse events of vaccines than the morbidity and mortality associated with disease. We need to be vigilant in maintaining the immunization program. If we stop immunizing — and this has been shown over and over again — these diseases come back. They are not going to go away. Every year in the US approximately 4 million infants are born and need to be entered into the vaccine program. So we have to keep immunizing against the diseases that are listed in the vaccine schedule" Dr. Pickering said.

Dr. Pickering will present Saturday’s keynote address, "What's new with the Red Book," at the 22nd Annual Infectious Diseases in Children Symposium in New York City, November 21-22, 2009. Click here to learn more about this educational 2-day symposium for pediatric professionals. — By Pat Nale

For more information:

Centers for Disease Control and Prevention. Recommendations and guidelines: Advisory Committee on Immunization Practices (ACIP). www.cdc.gov/vaccines/recs/acip/.
Centers for Disease Control and Prevention. Reduction in rotavirus after vaccine introduction — United States, 2000-2009. MMWR Morb Mortal Wkly Rep. 2009;58(41):1146-1149.
American Academy of Pediatrics. Pickering LK, Baker CJ, Kimberlin DW, Long SS eds. Red Book 2009: Report of the Committee on Infectious Diseases, 28th ed. Elk Grove Village, Ill, American Academy of Pediatrics, 2009.