Published: 6 September 2018

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Intussusception: A Very Rare Risk After Rotavirus Vaccination

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Prescriber Update 39(3): 40–41
September 2018

Introduction

Intussusception is the most common abdominal emergency in young children¹. Intussusception refers to the telescoping of a segment of the intestine into itself^1,2.

It typically presents between 6 and 36 months of age¹. The incidence of intussusception is highest in the first to third years of life, although about 10 percent of cases occur in children aged over 5 years¹. Most episodes occur in otherwise healthy and well-nourished children. There is a slight male predominance, with a male: female ratio around 3:2¹.

If intussusception is not relieved, the blood supply to the affected segment of the intestine may be compromised, resulting in ischaemia and possibly perforation. Untreated intussusception may be fatal³.

Causes

Approximately 75 percent of intussusception cases are idiopathic as no clear disease trigger or lead point is found¹. (A lead point is a lesion or variation in the intestine that is trapped by peristalsis and dragged into a distal segment of the intestine, causing intussusception¹.)

When a cause is identified, it may include viral infection, bacterial enteritis or an underlying medical condition^1,4 (Table 1).

Table 1: Identified causes of intussusception^a,b

Viral infections	Bacterial enteritis (caused by the following infections)	Underlying medical conditions
Rotavirus (including rotavirus vaccine) Adenovirus	Salmonella spp. Escherichia coli Shigella spp. Campylobacter spp.	Meckel diverticulum Polyps Small bowel lymphoma Duplication cysts Vascular malformations Immunoglobulin A vasculitis Cystic fibrosis

1. Vo NJ, Sato TT. 2018. Intussusception in children. In: UpToDate 29 June 2018. URL: www.uptodate.com/contents/intussusception-in-children (accessed 18 July 2018).
2. Kodikara H, Lynch A, Morreau P, et al. 2010. Ten-year review of intussusception at Starship Hospital: 1998–2007. New Zealand Medical Journal 123(1324): 32–40. URL: www.nzma.org.nz/__data/assets/pdf_file/0010/37459/kodikara.pdf (accessed 18 July 2018).

Rotavirus vaccine is the only medicine associated with the development of intussusception. A low level risk of 1–6 excess cases per 100,000 vaccinated infants has been documented in some countries⁵. The incidence of intussusception in New Zealand prior to the introduction of routine rotavirus vaccination was estimated as 56.1 cases per 100,000 per year in children aged under 1 year, similar to the worldwide average estimate of 74 cases per 100,000⁶.

The benefits of rotavirus vaccination continue to outweigh the risks of harm, but the vaccine should not be given to children with a history of intussusception or an uncorrected congenital malformation of the gastrointestinal tract^2,7.

Symptoms

The classic presentation is an infant or toddler with sudden onset of intermittent, severe, crampy, progressive abdominal pain accompanied by inconsolable crying and drawing up of the legs towards the abdomen. Episodes usually occur at 15- to 20-minute intervals and become more frequent and severe over time. Vomiting may occur. A sausage-shaped abdominal mass may be felt in the abdomen. The stool is grossly bloody in nearly half of cases. In some cases, the stool may be a mixture of blood and mucous, giving it the appearance of redcurrant jelly. However, up to 20 percent of young infants have no obvious pain. Generally, some form of imaging is needed to confirm a diagnosis¹.

Parents and/or guardians should be advised to seek prompt medical advice if these symptoms occur after rotavirus vaccination⁷. Most children can be successfully treated with an enema (either air or fluid). However late diagnosis increases the likelihood that the child will require surgery⁴.

New Zealand cases linked to rotavirus vaccination

Rotavirus vaccine (as RotaTeq) was added to the New Zealand National Immunisation Schedule in 2014. Rotarix replaced RotaTeq on the Schedule in 2017.

As of 30 June 2018 the Centre for Adverse Reactions Monitoring had received 565 reports of suspected adverse reactions to rotavirus vaccine, in 11 cases the reaction was reported to be intussusception. The vaccine brand was reported as RotaTeq in nine cases and Rotarix in two cases. In nine cases the affected child was male. Ethnicity was reported as Māori in five cases, European in five cases and Pacific in one case. Intussusception was reported after the first and subsequent doses, consequently the age of the affected child ranged from 6 weeks to 5 months. The time between vaccination and onset of the reaction was reported in all cases and ranged from four days to two months. Recovery was reported in 10 of the 11 cases (in one case the outcome was unknown).

Please report any adverse reactions to rotavirus vaccine to CARM (https://nzphvc.otago.ac.nz/report/).

References

1. Vo NJ, Sato TT. 2018. Intussusception in children. In: UpToDate 29 June 2018. URL: www.uptodate.com/contents/intussusception-in-children (accessed 18 July 2018).
2. Ministry of Health. 2018. Immunisation Handbook 2017 (2^nd edn). Wellington: Ministry of Health. URL: www.health.govt.nz/publication/immunisation-handbook-2017 (accessed 18 July 2018).
3. Jiang J, Jiang B, Parashar U, et al. 2013. Childhood intussusception: A literature review. PLoS ONE 8(7): e68482. URL: www.ncbi.nlm.nih.gov/pmc/articles/PMC3718796/ (accessed 18 July 2018).
4. Kodikara H, Lynch A, Morreau P, et al. 2010. Ten-year review of intussusception at Starship Hospital: 1998–2007. New Zealand Medical Journal 123(1324): 32–40. URL: www.nzma.org.nz/__data/assets/pdf_file/0010/37459/kodikara.pdf (accessed 18 July 2018).
5. Burnett E, Parashar U, Tate J. 2018. Rotavirus vaccines: effectiveness, safety, and future directions. Paediatric Drugs 29(3): 223–33. URL: www.ncbi.nlm.nih.gov/pubmed/29388076 (accessed 23 July 2018).
6. Rosie B, Dalziel SR, Wilson E, et al. 2016. Epidemiology of intussusception in New Zealand pre-rotavirus vaccination. New Zealand Medical Journal 129(1442): 36–45. URL: www.nzma.org.nz/__data/assets/pdf_file/0016/51424/Best-FINAL.pdf (accessed 20 July 2018).
7. GlaxoSmithKline NZ Limited. 2018. Rotarix Human Rotavirus (Live Attenuated Oral Vaccine) Oral Liquid New Zealand Data Sheet 30 April 2018. URL: www.medsafe.govt.nz/profs/Datasheet/r/Rotarixliquidvac.pdf (accessed 18 July 2018).