Abstract
Background:
The introduction of rotavirus vaccines in the United States in 2006 and 2008 have had large impacts on reducing rotavirus- and diarrhea-associated healthcare utilization. We evaluated changes in diarrhea-associated mortality from 2005–2024 among children aged 1–59 months.
Methods:
We examined diarrhea-associated deaths, identified by International Classification and Diagnostic codes related to diarrhea listed anywhere on the death certificate, reported to the National Center for Health Statistics from 2005–2024. Diarrhea-associated death rates were calculated using national census data. Rate ratios and 95% confidence intervals were calculated by Poisson regression.
Results:
From 2005–2024, 6,993 diarrhea-associated deaths of children aged 1–59 months were reported. The rate of diarrhea-associated deaths decreased by 41%, from 2.36/100,00 in 2005–2006 to 1.38/100,000 in 2022–2024. Mortality rates were higher among infants aged 1–3 months, males, Black children, and non-Hispanic children. Differences in mortality rates across demographic groups decreased over time. Overall, 94% of diarrhea-associated deaths were of unspecified etiology. Prior to vaccine introduction, diarrhea-associated death rates were higher during the rotavirus season (January-June) within the 4–11 months and 12–23 months age groups; however, no distinct seasonality was observed after vaccine introduction (2008–2024).
Conclusions:
Diarrhea-associated mortality has declined in the United States. The diminished seasonality of deaths during the rotavirus season in the age groups most susceptible to rotavirus suggests that vaccines likely contributed, among other factors, to declines in U.S. diarrhea-associated mortality over the past two decades. However, the lack of specified etiology for most diarrhea-associated deaths precludes definitive attribution.
Keywords: Rotavirus, diarrhea, mortality
Introduction
Prior to the introduction of rotavirus vaccines in 2006 and 2008, rotavirus was the leading cause of severe diarrhea among children in the United States (U.S.)1–3. During the pre-vaccine period, rotavirus was estimated to be associated with 5% of all U.S. childhood hospitalizations and to cause 55,000–70,000 hospitalizations and 20–40 deaths per year in children <5 years of age1–3. Twenty years after vaccine introduction, rotavirus vaccines have had dramatic impacts on reducing rotavirus- and diarrhea-associated healthcare utilization and been shown to be highly effective in reducing rotavirus-associated emergency department visits and hospitalizations4.
Rotavirus vaccines are most effective against the most severe rotavirus disease, as measured by the modified Vesikari Severity Score, among children with rotavirus-associated emergency department visits and hospitalizations5. This finding suggests that rotavirus vaccines are also likely effective at preventing the most severe outcome of death. However, rotavirus vaccine effectiveness against mortality has not been calculated because rotavirus deaths are relatively rare in the context of rotavirus vaccine trials and post-licensure vaccine effectiveness studies. Furthermore, since clinical rotavirus testing is not routine, and the cause of many diarrheal deaths is not specified, the impact of rotavirus vaccines on pediatric rotavirus and diarrheal deaths has been difficult to assess both in the U.S. and globally6. A previous study assessed diarrhea-associated pediatric deaths in the U.S. from 2005–20167. Here, we include an additional 8 years of death records to evaluate the impact of rotavirus vaccines on diarrhea-associated mortality in U.S. children 1–59 months of age.
Methods
Deaths among children 1–59 months of age reported via death certificate to the National Center for Health Statistics (NCHS) from 2005–2024 were analyzed. Diarrhea-associated deaths were identified by International Classification and Diagnostic codes (ICD-10) (see Table, Supplemental Digital Content 1). Rotavirus-associated deaths were identified by ICD-10 code A08.0. Deaths in which diarrhea was listed in any position on the death certificate (diarrhea-associated deaths) were included as the primary analysis, with a secondary analysis for deaths in which diarrhea was listed as the underlying cause.
National census data were used to determine population sizes for rate calculations. Diarrhea-associated death rates per 100,000 children were calculated by age, sex, race, ethnicity, and over time. To determine if diarrheal deaths disproportionally occurred during the rotavirus season (January-June), diarrhea-associated mortality rates were calculated by month8–11. Data from 2005 and 2006 were used to represent the pre-vaccine period. Deaths from 2007 were excluded from analyses comparing pre- and post-vaccine data, as this was considered a transitional year. Subsequent post-vaccine introduction time periods were determined by rotavirus vaccine availability, uptake, and considerations regarding the COVID-19 pandemic. Due to changes in how the census collected and reported race during the study period, standardized race categories of White, Black, and Other Race were used. Rate ratios (RR) and 95% confidence intervals (CI) were calculated by Poisson regression.
Results
From 2005–2024, 6,993 diarrhea-associated deaths of children aged 1–59 months were reported to NCHS. Seventy-three percent (5,124) of diarrhea-associated deaths occurred in infants 1–3 months of age, 16% (1,124) of diarrhea-associated deaths were among the 4–11-month age group, and the 12–23 (372) and 24–59 (373) month age groups each accounted for 5% of diarrhea-associated deaths. Diarrhea was listed as the underlying cause in 4,960 (71%) of all diarrhea-associated deaths.
The etiology of diarrhea was unspecified for 94% of diarrhea-associated deaths, whereas 6% had a specified pathogen. The proportion of cases with a specified etiology increased with increasing age, ranging from just 2% in infants 1–3 months of age to 33% in children 24–59 months of age (Figure 1). The proportion of deaths with a specified etiology increased slightly from 6% in 2005–2006 to 11% in 2022–2024. From 2005–2024, rotavirus was listed on the death certificate of 48 children and listed as the underlying cause of death for 35 children.
Figure 1. Number of diarrhea-associated deaths and proportion without a specified etiology, by age group, United States 2005–2024.
The number of diarrhea-associated deaths and etiologies were determined by ICD-10 codes listed anywhere on the death certificate.
Following the introduction of rotavirus vaccines, the diarrhea-associated mortality rate among children 1–59 months progressively decreased over time, from 2.36/100,000 in 2005–2006 to 1.38/100,000 in 2022–2024, a 41% reduction (RR 0.59 (95% CI 0.53–0.65)) (Figure 2, see Table Supplemental Digital Content 2). The annual average number of diarrhea-associated deaths decreased from 462 in 2005–2006 to 252 in 2022–2024. The death rate was greatest among infants 1–3 months, and a 43% reduction (RR 0.57 (95% CI 0.51–0.64)) was observed over time in this age group, decreasing from 31.77/100,000 in 2005–2006 to 18.05/100,000 in 2022–2024. Diarrhea death rates decreased with increasing age, and over time, the death rates decreased to varying degrees, with children 24–59 months having a very low and relatively stable death rate (see Table Supplemental Digital Content 2). Similar trends were observed when only analyzing deaths in which diarrhea was listed as the underlying cause of death (Figure 2, see Table Supplemental Digital Content 3).
Figure 2. Diarrhea mortality rates over time among children age 1–59 months, United States 2005–2024.
Mortality rates were calculated for deaths in which diarrhea appeared anywhere on the death certificate (diarrhea-associated) or as the underlying cause of death (diarrhea underlying). Rates calculated per 100,000 children. Asterisks indicate the years the rotavirus vaccines were licensed in the United States, February 2006 for RotaTeq and April 2008 for Rotarix.
Diarrhea-associated death rates differed by sex, race, and ethnicity. Males had a slightly higher diarrhea-associated death rate than females, and non-Hispanic children had slightly higher rates than Hispanic children, but by 2022–2024, the difference between sexes and by ethnicity was negligible (Table 1, see Table Supplemental Digital Content 2). Prior to vaccine introduction, Black children (6.21/100,000 in 2005–2006) had higher diarrhea-associated death rates than White children (1.64/100,000 in 2005–2006) or children of other races (1.47/100,000 in 2005–2006); however, the rate and magnitude of difference decreased over time (2022–2024: Black (3.06/100,000), White (1.08/100,000), Other races (0.95/100,000)). The rate ratio comparing the mortality rate among Black children to that of White children in the pre-vaccine period was 3.78 (95% CI 3.31–4.32) and this decreased to 2.83 (95% CI 2.43–3.30) in the 2022–2024 period (Table 1). The reduction in mortality rates from the pre-vaccine period to most recent years (2022–2024) was greatest among Black children, where a 51% reduction was observed (rate ratio 0.49 (95% CI 0.42–0.58). Similar trends were observed when only analyzing deaths in which diarrhea was listed as the underlying cause of death (see Table, Supplemental Digital Content 3).
Table 1. Diarrhea-associated mortality rate ratios among children age 1–59 months, by time period and demographic characteristics, United States 2005–2024.
Rates were calculated per 100,000 children; rate ratios were calculated by Poisson regression using the noted reference groups. The average annual number of diarrhea-associated deaths, in which diarrhea was listed anywhere on the death certificate, were quantified.
| Pre-Rotavirus Vaccine | Post-Rotavirus Vaccine | |||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 2005–2006 | 2008–2010 | 2011–2013 | 2014–2019 | 2020–2021 | 2022–2024 | |||||||
| Death Rate (Number) | Rate Ratio (95% CI) | Death Rate (Number) | Rate Ratio (95% CI) | Death Rate (Number) | Rate Ratio (95% CI) | Death Rate (Number) | Rate Ratio (95% CI) | Death Rate (Number) | Rate Ratio (95% CI) | Death Rate (Number) | Rate Ratio (95% CI) | |
| Sex | ||||||||||||
| Female | 2.03 (195) |
Ref | 2.02 (196) |
Ref | 1.51 (145) |
Ref | 1.39 (132) |
Ref | 0.97 (89) |
Ref | 1.31 (117) |
Ref |
| Male | 2.67 (268) |
1.32
(1.16–1.50) |
2.72 (277) |
1.35
(1.22–1.50) |
1.93 (194) |
1.28
(1.13–1.44) |
1.66 (166) |
1.20
(1.09–1.32) |
1.54 (148) |
1.59
(1.32–1.91) |
1.46 (136) |
1.11 (0.96–1.28) |
| Age | ||||||||||||
| 1–3 mo | 31.77 (320) |
199.39
(143.74–276.58) |
36.19 (364) |
249.09
(189.08–328.16) |
26.33 (261) |
190.83
(143.37–253.98) |
22.36 (219) |
143.62
(118.42–174.18) |
19.51 (178) |
168.73
(114.10–249.51) |
18.05 (165) |
92.21
(71.32–119.22) |
| 4–11 mo | 3.47 (93) |
21.76
(15.35–30.85) |
2.62 (70) |
18.03
(13.34–24.37) |
1.72 (45) |
12.45
(9.00–17.21) |
1.80 (47) |
11.53
(9.27–14.36) |
1.46 (36) |
12.62
(8.10–19.66) |
1.89 (46) |
9.66
(7.20–12.95) |
| 12–23 mo | 0.77 (31) |
4.81
(3.21–7.21) |
0.52 (21) |
3.57
(2.47–5.14) |
0.41 (16) |
2.98
(2.01–4.42) |
0.36 (14) |
2.31
(1.74–3.06) |
0.25 (10) |
2.20
(1.22–3.95) |
0.54 (20) |
2.74
(1.93–3.90) |
| 24–59 mo | 0.16 (19) |
Ref | 0.15 (18) |
Ref | 0.14 (17) |
Ref | 0.16 (19) |
Ref | 0.12 (14) |
Ref | 0.20 (22) |
Ref |
| Race | ||||||||||||
| White | 1.64 (248) |
Ref | 1.76 (265) |
Ref | 1.26 (187) |
Ref | 1.13 (164) |
Ref | 0.99 (130) |
Ref | 1.08 (136) |
Ref |
| Black | 6.21 (194) |
3.78
(3.31–4.32) |
5.57 (185) |
3.17
(2.85–3.54) |
3.85 (129) |
3.05
(2.68–3.47) |
3.35 (112) |
2.97
(2.70–3.28) |
2.85 (84) |
2.87
(2.37–3.49) |
3.06 (91) |
2.83
(2.43–3.30) |
| Other | 1.47 (20) |
0.90 (0.65–1.24) |
1.55 (23) |
0.88 (0.69–1.13) |
1.47 (23) |
1.16 (0.91–1.50) |
1.40 (23) |
1.24
(1.04–1.49) |
0.83 (23) |
0.84 (0.61–1.15) |
0.95 (26) |
0.87 (0.69–1.11) |
| Ethnicity | ||||||||||||
| Hispanic | 2.09 (96) |
Ref | 2.10 (105) |
Ref | 1.45 (73) |
Ref | 1.40 (71) |
Ref | 1.20 (59) |
Ref | 1.28 (64) | Ref |
| Non-Hispanic | 2.42 (363) |
1.12 (0.99–1.35) |
2.45 (366) |
1.17
(1.03–1.32) |
1.79 (262) |
1.24
(1.07–1.44) |
1.56 (225) |
1.12
(1.00–1.25) |
1.27 (177) |
1.06 (0.86–1.30) |
1.40 (186) |
1.09 (0.93–1.29) |
Historically, the U.S. rotavirus season occurs from January through June. We observed higher monthly diarrhea-associated mortality rates from January-May during the pre-vaccine period (2005–2006) within the 4–11 and 12–23 months age groups (Figure 3); however, we did not observe elevated monthly mortality rates in these two age groups during these months following rotavirus vaccine introduction (2008–2024). No clear seasonal trends were seen in the 1–3- or 24–59-month age groups pre- or post-vaccine introduction. Similar trends were observed when the COVID-19 pandemic years were excluded and when we analyzed deaths in which diarrhea was listed as the underlying cause of death.
Figure 3. Diarrhea-associated deaths by age and month of death, United States 2005–2024.
Mortality rates per 100,000 children were calculated for deaths in which diarrhea appeared anywhere on the death certificate. The pre-vaccine period was defined as 2005–2006, while the post-vaccine period included 2008–2024. The rotavirus season was defined as January-June (shaded grey).
Discussion
In the nearly 20 years since rotavirus vaccines were introduced into the U.S. pediatric vaccine schedule, the rate of diarrhea-associated deaths in children age 1–59 months has decreased by 41%. Improvements in rehydration treatment for diarrhea, nutrition, water quality, and sanitation might account, in part, for these changes in mortality12. Regardless, in addition to these factors, our data suggest that the implementation of rotavirus vaccination may have contributed to the observed decline. First, infants age 4–11 months saw the greatest decrease in diarrhea-associated mortality rates from the pre-vaccine period to 2022–2024, with rates decreasing by 45%. This age group, which is the most susceptible to rotavirus infection and during which the rotavirus vaccine series is completed, has also seen the greatest decline in diarrhea- and rotavirus-associated hospitalizations following rotavirus vaccine introduction13. Second, prior to rotavirus vaccine introduction, we saw greater monthly diarrhea mortality rates during the historic rotavirus season months than during the non-season months. This pattern of elevated mortality during the rotavirus season was diminished following the introduction of rotavirus vaccines. Lastly, the decline in diarrhea-associated mortality rates correspond to increasing rotavirus vaccine coverage over time14–20. Despite these suggestive findings, the lack of specified etiology for the vast majority of deaths and the preponderance of deaths in the 1–3-month age group, which are likely multifactorial in nature, precludes firm conclusions about the role of rotavirus vaccines in reducing diarrhea-associated mortality in U.S. children.
The Infectious Disease Society of America Clinical Practice Guidelines for the Diagnosis and Management of Infectious Diarrhea does not include a strong recommendation for widespread laboratory testing in previously healthy, immunocompetent individuals experiencing acute watery, non-bloody diarrhea, as this is often of viral origin, short duration, and is self-resolving6. Laboratory testing of fatal cases can be particularly challenging, as some may have occurred outside of the hospital or shortly after hospital presentation, and specimens may not have been obtained for laboratory testing. For these reasons, rotavirus-associated healthcare encounters and deaths are undercounted when relying on deaths with a specific ICD code for rotavirus21, 22. There were 48 deaths with a rotavirus-specific ICD-10 code in our dataset; however, this is likely an undercount of the true number of rotavirus-associated deaths. To further assess diarrhea-associated deaths that are likely due to rotavirus, deaths occurring during the rotavirus season were analyzed. Studies have shown similar seasonality of all-cause acute gastroenteritis emergency department visits and rotavirus-specific emergency department visits, and unspecified viral diarrhea hospitalizations and rotavirus-specific hospitalizations, suggesting that some of these unspecified diarrhea illnesses may be due to rotavirus3, 23.
The lowest diarrhea-associated mortality rate was observed during the 2020–2021 period. This corresponds with the COVID-19 pandemic, during which non-pharmaceutical prevention measures were being implemented and behaviors changed. School and business closures, physical distancing, mask use, and other mitigation methods such as hand-washing and increased disinfectant utilization during the COVID-19 pandemic may have impacted the transmission of other diseases transmitted from person-to-person, including rotavirus and other diarrheal illnesses. Laboratory testing reports to the National Respiratory and Enteric Surveillance System (NREVSS) showed a decrease in rotavirus activity from 2020–202124. The decrease in rotavirus activity, coupled with lower rotavirus vaccine coverage rates among children born during 2020–2021 may have resulted in an increase in rotavirus-susceptible children during the 2021–2022 rotavirus season and may have contributed to the slight increase in diarrhea-associated mortality rates observed during the 2022–2024 period24.
We observed that diarrhea-associated mortality rates were greater among Black children than White children. Previous studies have observed differences in the burden of disease and fatality rate by race. A study analyzing U.S. hospital discharge data from 1993–2003 found that Black and Hispanic children <5 years of age had a greater cumulative occurrence of diarrhea-coded hospitalizations by 12 months of age than White children3. In addition to Black children being at greater risk of being hospitalized, they were also at greater risk of dying during a rotavirus-associated hospitalization than White children (risk ratio 2.4, 95% CI 1.2–4.7)3. The difference in diarrhea-mortality rates between Black and White children has been slowly decreasing in magnitude over time.
There are a few limitations to note. First, the pre-vaccine baseline period we used was very short. Errors in ICD-10 code assignments during the transition from ICD-9 to ICD-10 resulted in miscoding that makes data on diarrheal deaths from 1999–2004 unusable. This, combined with the lack of routine clinical testing, resulted in only a small number of ICD-10-specified rotavirus-associated deaths and we were not able to comment on rotavirus-specific mortality rates. Secondly, due to changes in how race was captured by the national census, we were limited to using categories of White, Black, and Other for the race categories. This may result in us missing important differences in mortality rates among the races grouped together in the “Other” category. Lastly, rotavirus seasonality can be difficult to define and has been shifting over time. Rotavirus disease historically exhibited a seasonal pattern with greatest activity from December/January to April/May; however, following vaccine introduction, rotavirus seasons have been shorter and start later9–11. Our analysis did not account for these shifts in the rotavirus season and did not account for geographic location, which has been shown to impact the timing of rotavirus activity8.
In conclusion, we have observed a 41% decrease in diarrhea-associated mortality rates in children under the age of 5 years following rotavirus vaccine introduction in the United States. Multiple factors likely accounted for the declines in diarrheal deaths, and some evidence suggests that rotavirus vaccination contributed, but firm conclusions are not possible given the non-specific nature of the data. Continued monitoring of rotavirus burden and outcomes is needed to further assess the impact of rotavirus vaccines on rotavirus- and diarrhea-associated mortality.
Supplementary Material
Footnotes
Conflicts of Interest
The authors declare no conflicts of interest.
Disclaimer
The findings and conclusions of this report are those of the authors and do not necessarily represent the official position of the US Centers for Disease Control and Prevention.
Data Availability Statement.
The datasets analyzed during the current study are publicly available through CDC WONDER.
References
- 1.Charles MD, Holman RC, Curns AT, et al. Hospitalizations associated with rotavirus gastroenteritis in the United States, 1993–2002. Pediatr Infect Dis J. 2006;25(6):489–93. [DOI] [PubMed] [Google Scholar]
- 2.Malek MA, Curns AT, Holman RC, et al. Diarrhea- and rotavirus-associated hospitalizations among children less than 5 years of age: United States, 1997 and 2000. Pediatrics. 2006;117(6):1887–92. [DOI] [PubMed] [Google Scholar]
- 3.Fischer TK, Viboud C, Parashar U, et al. Hospitalizations and deaths from diarrhea and rotavirus among children <5 years of age in the United States, 1993–2003. J Infect Dis. 2007;195(8):1117–25. [DOI] [PubMed] [Google Scholar]
- 4.Pindyck T, Tate JE, Parashar UD. A decade of experience with rotavirus vaccination in the United States - vaccine uptake, effectiveness, and impact. Expert Rev Vaccines. 2018;17(7):593–606. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Diallo AO, Wikswo ME, Sulemana I, et al. Rotavirus Vaccine Effectiveness Against Severe Acute Gastroenteritis: 2009–2022. Pediatrics. 2024;154(4). [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Shane AL, Mody RK, Crump JA, et al. 2017 Infectious Diseases Society of America Clinical Practice Guidelines for the Diagnosis and Management of Infectious Diarrhea. Clin Infect Dis. 2017;65(12):1963–73. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Aliabadi N, Pham H, Curns AT, et al. Diarrhea-Associated Mortality in Children Less Than 5 Years of Age in the United States, 2005–2016. Pediatr Infect Dis J. 2019;38(7):e153–e4. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Burnett E, Parashar UD, Winn A, et al. Major Changes in Spatiotemporal Trends of US Rotavirus Laboratory Detections After Rotavirus Vaccine Introduction-2009–2021. Pediatr Infect Dis J. 2022;41(9):759–63. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Turcios RM, Curns AT, Holman RC, et al. Temporal and geographic trends of rotavirus activity in the United States, 1997–2004. Pediatr Infect Dis J. 2006;25(5):451–4. [DOI] [PubMed] [Google Scholar]
- 10.Tate JE, Haynes A, Payne DC, et al. Trends in national rotavirus activity before and after introduction of rotavirus vaccine into the national immunization program in the United States, 2000 to 2012. Pediatr Infect Dis J. 2013;32(7):741–4. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Hallowell BD, Parashar UD, Curns A, et al. Trends in the Laboratory Detection of Rotavirus Before and After Implementation of Routine Rotavirus Vaccination - United States, 2000–2018. MMWR Morb Mortal Wkly Rep. 2019;68(24):539–43. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Cortese MM, Parashar UD, Centers for Disease C, et al. Prevention of rotavirus gastroenteritis among infants and children: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2009;58(RR-2):1–25. [PubMed] [Google Scholar]
- 13.Leshem E, Tate JE, Steiner CA, et al. Acute gastroenteritis hospitalizations among US children following implementation of the rotavirus vaccine. JAMA. 2015;313(22):2282–4. [DOI] [PubMed] [Google Scholar]
- 14.Hill HA, Elam-Evans LD, Yankey D, et al. National, State, and Selected Local Area Vaccination Coverage Among Children Aged 19–35 Months - United States, 2014. MMWR Morb Mortal Wkly Rep. 2015;64(33):889–96. [DOI] [PubMed] [Google Scholar]
- 15.Hill HA, Elam-Evans LD, Yankey D, et al. Vaccination Coverage Among Children Aged 19–35 Months - United States, 2017. MMWR Morb Mortal Wkly Rep. 2018;67(40):1123–8. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.Hill HA, Singleton JA, Yankey D, et al. Vaccination Coverage by Age 24 Months Among Children Born in 2015 and 2016 - National Immunization Survey-Child, United States, 2016–2018. MMWR Morb Mortal Wkly Rep. 2019;68(41):913–8. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17.Hill HA, Yankey D, Elam-Evans LD, et al. Vaccination Coverage by Age 24 Months Among Children Born in 2016 and 2017 - National Immunization Survey-Child, United States, 2017–2019. MMWR Morb Mortal Wkly Rep. 2020;69(42):1505–11. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.Hill HA, Chen M, Elam-Evans LD, et al. Vaccination Coverage by Age 24 Months Among Children Born During 2018–2019 - National Immunization Survey-Child, United States, 2019–2021. MMWR Morb Mortal Wkly Rep. 2023;72(2):33–8. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19.Hill HA, Yankey D, Elam-Evans LD, et al. Vaccination Coverage by Age 24 Months Among Children Born in 2019 and 2020 - National Immunization Survey-Child, United States, 2020–2022. MMWR Morb Mortal Wkly Rep. 2023;72(44):1190–6. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20.Hill HA, Yankey D, Elam-Evans LD, et al. Decline in Vaccination Coverage by Age 24 Months and Vaccination Inequities Among Children Born in 2020 and 2021 - National Immunization Survey-Child, United States, 2021–2023. MMWR Morb Mortal Wkly Rep. 2024;73(38):844–53. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21.Hsu VP, Staat MA, Roberts N, et al. Use of active surveillance to validate international classification of diseases code estimates of rotavirus hospitalizations in children. Pediatrics. 2005;115(1):78–82. [DOI] [PubMed] [Google Scholar]
- 22.Jayasinghe S, Macartney K. Estimating rotavirus gastroenteritis hospitalisations by using hospital episode statistics before and after the introduction of rotavirus vaccine in Australia. Vaccine. 2013;31(6):967–72. [DOI] [PubMed] [Google Scholar]
- 23.Shah MP, Tate JE, Steiner CA, et al. Decline in Emergency Department Visits for Acute Gastroenteritis Among Children in 10 US States After Implementation of Rotavirus Vaccination, 2003 to 2013. Pediatr Infect Dis J. 2016;35(7):782–6. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24.Burnett E, Parashar UD, Winn A, et al. Trends in Rotavirus Laboratory Detections and Internet Search Volume Before and After Rotavirus Vaccine Introduction and in the Context of the Coronavirus Disease 2019 Pandemic-United States, 2000–2021. J Infect Dis. 2022;226(6):967–74. [DOI] [PMC free article] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
The datasets analyzed during the current study are publicly available through CDC WONDER.