Day: March 25, 2019

How Long Does Fecal Shedding Occur for Oral Vaccines?

Patient Presentation
A 78-day-old female came to clinic because her mother was concerned that her stools were “diarrheal.” She was breastfed and her mother said that her stools were “always loose.” For the past 3 weeks her stools were more frequent (4-5 times/day) of loose, pudding-like stools without blood, mucous or changes in color. They were yellow in color, and not foul-smelling nor voluminous. Her mother was concerned because her mother was visiting from another country and had had diarrhea. The baby was feeding well and acting well otherwise. The past medical history showed she was a full-term, first-born infant without significant past medical history. She had received her regular well child care at 63 days of life and received all of her vaccinations including rotavirus vaccine.

The pertinent physical exam showed an interactive infant without distress. Her weight was increasing at 26 grams/day since her well child care visit. Her examination was normal. The fresh stool in the clinic appeared consistent with the mother’s description and looked normal to the pediatrician.

The diagnosis of a healthy infant with normal stools but exposure to a relative with diarrhea was made. The mother was quite concerned about the possibility of an infectious diarrhea transmitted from the grandmother, therefore a stool enteric panel was run. The laboratory evaluation was negative for any other infectious process except was positive for rotavirus. The pediatrician felt this was due to shedding of the rotavirus vaccine and not a cause of diarrhea. The parent was informed of the results and continued to monitor the infant at home.

Discussion
Vaccination has reduced infectious disease morbidity and mortality since its introduction. Vaccines can be given intramuscularly, subcutaneously or orally. Oral virus vaccines currently used in the US include rotavirus, cholera, typhoid and adenovirus. Adenovirus vaccine is used in military personnel. As these are attenuated viruses there is concern for household contacts who are immunocompromised who may inadvertently be exposed to the virus through fecal shedding. Additionally, there is a concern that the attenuated virus may mutate and revert back to its wild-form and potentially cause disease.

Injectable polio vaccine is used in the U.S. and oral polio vaccine (OPV) is not used. Wild type polio type 2 was officially eradicated in 2015, and type 3 has not been detected globally since 2012, leaving type 1 as the most common circulating type.

The World Health Organization states in May 2012 that “…at least one dose of inactivated poliomyelitis vaccine (IPV) should be introduced into all routine immunization programmes globally, and trivalent oral polio vaccines (tOPV) will be replaced with bivalent (bOPV) in all OPV-using countries. The global “OPV Switch” was successfully conducted worldwide in April 2016 – setting the stage for the eventual withdrawal of all OPV.”

Learning Point
In an Australian birth cohort study in 2017, rotavirus was detected in 9.6% of stool swabs. “Proportions of infants shedding RotaTeq after first, second and third vaccine doses were 87.0%, 57.4% and 47.3%, respectively,…” with median durations of 3 (range 1-8), 1.5 (1-3) and 1 (1-2) weeks respectively. Other studies cite similar time frames. Per the American Academy of Pediatrics RedBook® “Infants living in households with immunocompromised people can be immunized. Highly immunocompromised patients should avoid handling diapers of infants who have been vaccinated with rotavirus vaccine for 4 weeks after vaccination.”

Cholera vaccine (VaxChora®) is known for shedding for at least the first 7 days but length of shedding has not been determined.

In a 2005 study of oral typhoid vaccine, fecal shedding was not detected at 7 or greater days after vaccination.
The American Academy of Pediatrics RedBook® do not currently have recommendations regarding infants living in households with immunocompromised people for cholera and typhoid vaccine.

For wild polio the “[v]irus persists in the throat for approximately 1 to 2 weeks after onset of illness and is excreted in feces for 3 to 6 weeks. Patients potentially are contagious as long as fecal excretion persists. In recipients of OPV, virus also persists in the throat for 1 to 2 weeks and is excreted in feces for several weeks, although in rare cases excretion for more than 2 months can occur. ” “IPV is recommended for these [infants and others who have immunocompromised household contacts], and OPV should not be used. If OPV inadvertently is introduced into a household of an immunocompromised or HIV-infected person, close contact between the patient and the OPV recipient should be minimized for approximately 4 to 6 weeks after immunization.”

Questions for Further Discussion
1. How common is rotavirus infection and what problems does it cause?

2. What vaccine properties cause them to be given intramuscularly, subcutaneously or orally?

3. What other diseases are vaccines being developed for?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.
Information prescriptions for patients can be found at MedlinePlus for these topics: Immunization and Rotavirus Infections.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

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The novel oral typhoid vaccine M01ZH09 is well tolerated and highly immunogenic in 2 vaccine presentations.
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Use of RapidChek® SELECTTM Salmonella to detect shedding of live attenuated Salmonella enterica serovar Typhi vaccine strains. J Microbiol Methods. 2012 May;89(2):137-47.

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Following oral vaccination as measured by quantitative reverse transcription-PCR versus culture. J Clin Microbiol. 2015 Jan;53(1):206-11.

Vaxchora (Cholera vaccine, live, oral) prescribing information Redwood City, California: PaxFax, inc.: 2016.
Available from the Internet at: https://www.fda.gov/downloads/biologicsbloodvaccines/vaccines/approvedproducts/ucm506235.pdf

Mosley JF 2nd, Smith LL, Brantley P, Locke D, Como M.Vaxchora: The First FDA-Approved Cholera Vaccination in the United States. P T. 2017 Oct;42(10):638-640.

Famulare M, Selinger C, McCarthy KA, Eckhoff PA, Chabot-Couture G.
Assessing the stability of polio eradication after the withdrawal of oral polio vaccine. PLoS Biol. 2018 Apr 27;16(4):e2002468.

American Academy of Pediatrics. Cholera, In Kimberlin, DW, Brady, MT, Jackson, M, and Long SS. eds. Red Book: 2018-21 Report of the Committee on Infectious Diseases. 30th edit. Elk Grove Village, IL: American Academy of Pediatrics; 2018.
Available from the Internet at https://redbook.solutions.aap.org/chapter.aspx?sectionid=189640178&bookid=2205 (cited 1/11/19).

American Academy of Pediatrics. Polio, In Kimberlin, DW, Brady, MT, Jackson, M, and Long SS. eds. Red Book: 2018-21 Report of the Committee on Infectious Diseases. 30th edit. Elk Grove Village, IL: American Academy of Pediatrics; 2018.
Available from the Internet at https://redbook.solutions.aap.org/chapter.aspx?sectionid=88187218&bookid=1484 (cited 1/11/19).

American Academy of Pediatrics. Rotavirus, In Kimberlin, DW, Brady, MT, Jackson, M, and Long SS. eds. Red Book: 2018-21 Report of the Committee on Infectious Diseases. 30th edit. Elk Grove Village, IL: American Academy of Pediatrics; 2018.
Available from the Internet at https://redbook.solutions.aap.org/chapter.aspx?sectionid=189640175&bookid=2205 (cited 1/11/19).

American Academy of Pediatrics. Salmonella, In Kimberlin, DW, Brady, MT, Jackson, M,and Long SS. eds. Red Book: 2018-21 Report of the Committee on Infectious Diseases. 30th edit. Elk Grove Village, IL: American Academy of Pediatrics; 2018.
Available from the Internet at https://redbook.solutions.aap.org/chapter.aspx?sectionid=189640178&bookid=2205 (cited 1/11/19).

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa