Vaccination failure; Rotavirus diarrhea; This case was reported in a literature article and described the occurrence of vaccination failure in a 14-week-old patient who received Rota (Rotarix liquid formulation) for prophylaxis.   Co-suspect products included Rota (Rotarix liquid formulation) for prophylaxis and Polio Bivalent T1 T3 oral (Oral polio vaccine) for prophylaxis.   On an unknown date, the patient received the 1st dose of Rotarix liquid formulation (oral), the 2nd dose of Rotarix liquid formulation (oral) and Oral polio vaccine (oral). On an unknown date, 56 days after receiving Rotarix liquid formulation, 28 days after receiving Rotarix liquid formulation and not applicable after receiving Oral polio vaccine, the patient experienced vaccination failure (serious criteria GSK medically significant) and diarrhea rotavirus (serious criteria GSK medically significant). On an unknown date, the outcome of the vaccination failure and diarrhea rotavirus were unknown.   The reporter considered the vaccination failure and diarrhea rotavirus to be related to Rotarix liquid formulation and Rotarix liquid formulation. The reporter considered the diarrhea rotavirus to be related to Oral polio vaccine.  Additional details were reported as follows: This case was reported in a literature article and described the vaccination failure in a infant patient of 14-weeks-old of unspecified gender who was vaccinated rotarix vaccine (GlaxoSmithKline) for prophylaxis.  The patient was the part of the phase IV double-blind, parallel group, randomized controlled trial from June 2017 through June 2018 at the community research clinic maintained by the International Centre, that aimed to compare vaccine take (primary outcome) among healthy infants randomized to receive either the standard dose or double the standard dose of oral Rotarix vaccine at 6 and 10 weeks of life. Also aimed to evaluate the effect of increased Rotarix inoculum on vaccine take among infants. They hypothesized that an increased vaccine inoculum would lead to improved vaccine take in this population. The study was registered at web site. [In this study, Healthy infants were enrolled within the first week of life. All the enrolled infants does not have any congenital malformations, birth (weight) or enrollment weight was more than the 2000 gm, does not had any immunocompromising condition infants. Infants were randomized using random permuted blocks. Randomization by unique study identification number (SID) was pre-determined 1:1 to the high-dose or standard-dose arm using random permuted blocks (block sizes 4 and 8). The 220 infants were enrolled and randomized (110 per group). By the 220, whom 189 completed the study per-protocol: 97 standard-dose and 92 high-dose infants completed the study per-protocol. The first infant was enrolled on 12th June 2017. Upon achieving targeting enrollment, the final infant was enrolled 25th February 2018 and completed the study on 7th June 2018]. The patient belongs to the high dose arm. No information on patient's medical or family history or concurrent condition or concomitant condition was provided. On unspecified date between 12th June 2017 to 7th June 2018, at the age of 6 week, the patient received 1st dose of oral rotarix vaccine and at the age of 10 week, the patient received 2nd oral rotarix vaccine (dosage unknown; batch number not provided) and 1 week following the rotarix vaccination and at the age of 11 week, the patient had received oral unspecified polio vaccine (OPV) as per the Expanded Programme on Immunizations (EPI) schedule. [In this study, Rotarix (RV) was a monovalent oral vaccine consisting of an live-attenuated, G1P strain of human rotavirus. It was pre-qualified by WHO in 2009 and was currently the most widely used RV vaccine in national immunization program. Rotarix was administered on a 2 doses schedule at 6 and 10 weeks of life on the WHO-recommended Expanded Programme on Immunizations (EPI) schedule. Infants in the high-dose arm received 2 doses of Rotarix, each consisting of 1.5 mL of clear liquid, at 6 and 10 weeks of life. Infants in the standard-dose arm received 1st dose of Rotarix (1.5 mL) and one equivalent volume of a sterile, pharmacy grade water at 6 and 10 weeks of life. The lot numbers of vaccines used in this study were AROLB475AI, AROLB580AB, AROLB834BF, AROLB855AA, AROLB832BH, AROLB910AE, AROLB884AF, and AROLB955BJ. To separate oral polio vaccine (OPV) from Rotarix administration, all children in the study received standard EPI vaccines (including OPV) one week following each Rotarix dose at the nearest EPI clinic. EPI vaccine history was recorded by the study team from each infant's immunization card. Infants were included in the per-protocol population if both vaccine doses were administered within the pre-specified window period for vaccination (week 6 + 7 days for dose 1 and 28-35 days later for dose 2), at least 1 mL of blood was successfully collected at both week 6 and week 14, the first two stool specimens following each vaccine dose were collected within the pre-specified window periods (3-4 days and 6-7 days post-vaccination), and the first dose of OPV was received no earlier than the day of surveillance stool collection at 6-7 days post-1st-dose]. On unspecified date between 12th June 2017 to 7th June 2018, 4 weeks after the 2nd dose of Rotarix, 3 weeks after OPV, the patient had an symptoms of diarrheal episodes. The patient's stool sample and plasma specimen has been taken for the RV-IgA measurement by enzyme immunoassay (EIA). The stool specimens were tested for RV by qRT-PCRa and positive specimens subsequently underwent conventional RT-PCR to amplify the RV VP8 gene segment followed by Sanger sequencing using VP4F and/or VP4R primers and BLAST analysis to confirm Rotarix vaccine-strain virus. The patient was found the positive for the wild-type strains and has been diagnosed with the two separate wild type asymptomatic infections (P [4] and P [6]), that was detected in three sequential stool specimens. [In this study, Vaccine take was defined as detection of post-vaccination fecal vaccine shedding by real-time reverse transcription polymerase chain reaction with sequence confirmation or plasma rotavirus-specific immunoglobulin A (RV-IgA) seroconversion 4 weeks following the 2nd dose. The vaccine take occurred in 62 high-dose infants versus 69 standard-dose infants. The plasma was collected from all infants pre-vaccination at 6 weeks and again 4 weeks post-dose 2 at 14 weeks for RV-IgA measurement by enzyme immunoassay (EIA). Seropositive was defined as RV-IgA equal or more than 20 U/mL. Seroconversion was defined as seronegative at week 6 pre-vaccination, converting to seropositive post-vaccination at week 14. Infants who were seropositive at week 6 were therefore considered negative for seroconversion analyses but included in analyses for post-vaccination seropositivity. RV-IgA EIA was performed in the research laboratory of the principal investigator. The stool specimens were collected by home visit within 3 days prior to each vaccine dose and 3-4 days, 6-7 days, and 13-14 days after 1st dose and 3-4 days, 6-7 days, and 13-16 days after 2nd dose 2. All stool specimens underwent total nucleic acid extraction with spiking of MS2 phage as RNA extraction. All extracts were tested for RV by qRT-PCR targeting the RV NSP3 gene segment. Amplification was performed on the CFX96 platform by using Ultraplex 1-step ToughMix. ST3-strain NSP3 was cloned into pFastBac1 and serial dilutions of known copy number. Positive specimens subsequently underwent conventional RT-PCR to amplify the RV VP8 gene segment followed by Sanger sequencing using VP4F and/or VP4R primers and BLAST analysis to confirm Rotarix vaccine-strain virus. Fecal vaccine shedding was defined as detection of vaccine strain virus in any scheduled post-vaccination stool specimen by quantitative real-time reverse transcription polymerase chain reaction (qRT-PCR) followed by vaccine strain sequence confirmation. PCR-positive surveillance stool specimens were also tested for RV antigen using the ProSpecT RV microplate EIA. Stool extraction, qRT-PCR, and stool EIA was performed. Positive specimens were transferred for RT-PCR in the laboratory of the principal investigator followed by Sanger sequencing by the core facility. Active diarrheal surveillance was initiated upon enrollment until study completion at 14 weeks of life. A diarrheal episode was defined as three or more abnormally loose stools (as determined by caregivers) within a 24-hour period. Specimens for each diarrheal episode were collected by home visit and tested for RV using both antigen and PCR detection. 41 infants in the standard-dose arm seroconverted following vaccination, compared to 42 infants in the high-dose Arm. Similar results were observed when the frequency of infants who were seropositive post-vaccination at week 14 (irrespective of baseline RV-IgA) was compared between groups: 42 infants in the standard-dose arm were seropositive post-vaccination compared to 46 infants in the high-dose arm. The overall frequency of fecal vaccine shedding by PCR detection was (N = 118). The kinetics of RV shedding, relative to each dose of Rotarix, by Using PCR detection, 63 infants in the standard-dose arm demonstrated fecal shedding of Rotarix vaccine in any stool specimen at any time point following vaccination, compared to 55 infants in the high-dose arm. After conducting the post-hoc analysis among participants with confirmed vaccine replication, following the first dose, 36 infants in the standard-dose arm had confirmed vaccine replication, compared to 29 infants in the high-dose arm. Following the second dose, 14 infants in the standard-dose arm had confirmed vaccine replication, compared to 17 infants. All PCR-positive specimens underwent stool RV antigen test by EIA. The limit of detection of typical stool RV antigen EIA was approximately 106 particles/mL, whereas the standard dose of Rotarix contains a 106.5 cell culture infective dose (CCID50) of virus, which corresponds to 106 fluorescent focus units (FFU). Detection by EIA only occurs following replication, which achieves stool viral concentrations equivalent to or in excess of the initial inoculum. The 33 patients had Rotarix sequence-confirmed specimens that were also EIA-positive: 19 in the standard-dose arm, compared to 14 in the high-dose arm. Among all PCR-positive stool specimens, 22 were positive for wild-type strains: 2 untypeable, 3 P [4], 3 P[6], and 14 P [8]. Nineteen infants (9 standard-dose, 10 high-dose) had wild-type asymptomatic infections, 10 of whom also shed Rotarix at other time points. One infant had two separate asymptomatic infections (P [4] and P [6]), and another had a single episode of asymptomatic P [4] infection that was detected in three sequential stool specimens. Among the nine who did not shed Rotarix, seven seroconverted, (three standard-dose, four high-dose), meaning seroconversion waslikelydueto natural infection and not vaccination.]. This case was considered of vaccination failure. This case has been considered as serious due to vaccination failure. Treatment was unknown. The outcome of the event was not provided. [In this study, the pre-specified primary outcome was vaccine take, defined as either RV-IgA seroconversion or detection of sequence-confirmed fecal vaccine shedding in any post-vaccination surveillance stool specimen, as described. The pre-specified secondary outcomes were RV-IgA seroconversion alone and fecal vaccine shedding alone. Additional post-hoc assessments were performed to assess RV-IgA seropositivity and three- and four-fold rise in antibody concentration following vaccination, frequency of fecal shedding specimens positive by stool RV antigen EIA, vaccine take using EIA-positive fecal shedding specimens, and to identify infants with confirmed replication of vaccine-strain virus. For vaccine replication analysis, they identified all infants with sequence-confirmed Rotarix shedding, but who demonstrated increasing stool viral burden (as evidenced by lower Cq values) in sequential stool specimens following either vaccine dose (i.e. lower Cq at day 6-7 or 2 weeks compared to Cq at day 3-4 or day 6-7]. The author commented, "Thus, it was unclear if an increased inoculum of vaccine could improve vaccine response, as assessed by vaccine take" (a composite measure of either post-vaccination antibody seroconversion or fecal vaccine shedding) in children in low-income countries. We did detect modestly elevated RV-IgA GMC in the high-dose group (116.3 U/mL vs 89.0 U/mL among seropositive infants). Overall, our results are consistent with the finding that oral vaccine immunogenicity, both in terms of frequency of RV-IgA seroconversion and of achievable antibody concentrations, are substantially lower in low-income countries. In contrast, we did observe in post-hoc analysis that children with vaccine replication or EIA-positive shedding had significantly higher RV-IgA responses, with RV-IgA GMC of 56.3 U/mL among children with confirmed vaccine replication vs 13.4 U/mL in those without, and GMC of 63.0 U/mL in those with EIA-detectable fecal shedding vs 21.7 U/mL in those without. The association between increased immunogenicity with vaccine replication. We defined vaccine replication via detection of increasing stool virus burden over time, which could only be achieved by viral replication. Using PCR detection allowed us to identify children with low-level replication that may have been below the limit of detection of stool EIA. Our results further confirm that the poor response to oral vaccines in low-income settings is strongly influenced by inability to successfully establish replicating gut infection, possibly due to impaired gut health and function. Since the current study used Rotarix, our results may not be generalizable to other vaccines. And finally, since RV-IgA is a suboptimal correlate of risk and vaccine efficacy in low-income countries, it is conceivable that increased inoculum could have had an effect on clinical protection that could not be captured within the scope of this study. However, we confirmed the role of vaccine-strain virus replication in enhanced immunogenicity, underscoring the importance of underlying gut health in responses to vaccine." The author concluded, "Administration of double the standard dose of an oral, live-attenuated rotavirus vaccine (Rotarix) did not improve vaccine take among infants in specific urban area. However, improved immunogenicity in children with vaccine replication irrespective of initial inoculum provides further evidence for the need to promote in-host replication and improved gut health to improve oral vaccine response in low-income settings". This is 1 of the 2 valid cases reported in this literature article.      Lab Comments: On unspecified date between 12th June 2017 to 7th June 2018, lab test were done. The patient's stool sample and plasma specimen has been taken for the RV-IgA measurement by enzyme immunoassay (EIA). The stool specimens were tested for RV by qRT-PCRa and positive specimens subsequently underwent conventional RT-PCR to amplify the RV VP8 gene segment followed by Sanger sequencing using VP4F and/or VP4R primers and BLAST analysis to confirm Rotarix vaccine-strain virus. The patient was found the positive for the wild-type strains and has been diagnosed with the two separate wild type asymptomatic infections (P [4] and P [6]), that was detected in three sequential stool specimens.