Diarrheal Etiology and Impact of Coinfections on Rotavirus Vaccine Efficacy Estimates in a Clinical Trial of a Monovalent Human-Bovine (116E) Oral Rotavirus Vaccine, Rotavac, India

Abstract

Background: Rotavirus vaccine efficacy (VE) estimates in low-resource settings are lower than in developed countries. We detected coinfections in cases of severe rotavirus diarrhea in a rotavirus VE trial to determine whether these negatively impacted rotavirus VE estimates.

Methods: We performed TaqMan Array Card assays for enteropathogens on stools from rotavirus enzyme immunoassay-positive diarrhea episodes and all severe episodes (Vesikari score ≥11), from a phase 3 VE trial of Rotavac, a monovalent human-bovine (116E) rotavirus vaccine, carried out across 3 sites in India. We estimated pathogen-specific etiologies of diarrhea, described associated clinical characteristics, and estimated the impact of coinfections on rotavirus VE using a test-negative design.

Results: A total of 1507 specimens from 1169 infants were tested for the presence of coinfections. Rotavirus was the leading cause of severe diarrhea even among vaccinated children, followed by adenovirus 40/41, Shigella/enteroinvasive Escherichia coli, norovirus GII, sapovirus, and Cryptosporidium species. Bacterial coinfections in rotavirus-positive diarrhea were associated with a longer duration of diarrhea and protozoal coinfections with increased odds of hospitalization. Using the test-negative design, rotavirus VE against severe rotavirus gastroenteritis increased from 49.3% to 60.6% in the absence of coinfections (difference, 11.3%; 95% confidence interval, -10.3% to 30.2%).

Conclusions: While rotavirus was the dominant etiology of severe diarrhea even in vaccinated children, a broad range of other etiologies was identified. Accounting for coinfections led to an 11.3% increase in the VE estimate. Although not statistically significant, an 11.3% decrease in VE due to presence of coinfections would explain an important fraction of the low rotavirus VE in this setting.

Keywords: attributable fraction; coinfection; diarrhea; rotavirus vaccine; vaccine efficacy.

Figure 1.

Selection and testing of stool specimens for enteropathogen coinfections from the ROTAVAC trial. Abbreviation: TAC, TaqMan Array Card.

Figure 2.

Pathogen-specific attribution of severe diarrhea by rotavirus vaccination status. Abbreviations: EIEC, enteroinvasive Escherichia coli; ST-ETEC, Stable toxin enterotoxigenic Escherichia coli; tEPEC, typical enteropathogenic Escherichia coli.

Figure 3.

Attribution to nonrotavirus enteropathogens in rotavirus enzyme immunoassay–positive severe diarrhea. Abbreviations: EIEC, enteroinvasive Escherichia coli; ST-ETEC, stable toxin enterotoxigenic Escherichia coli.