The future control of rotavirus disease: Can live oral vaccines alone solve the rotavirus problem?

•Oral rotavirus vaccines have been less effective in low income countries where they are needed most.•Given lower efficacy and current levels of coverage, RV remains a top cause of severe diarrhea.•Parenteral vaccines now in development provide an alternative strategy for improved immunization.•Development of parenteral RV vaccines should be accelerated to fully control RV disease. Live oral rotavirus (RV) vaccines used worldwide are most effective in reducing diarrheal hospitalizations from RV in high income countries and least effective in low income countries where RV remains a prime cause of death in children. Research has failed to fully explain the reason for this difference of efficacy for RV vaccines, an observation made with other live oral vaccines for polio, cholera and typhoid fever. Use of parenteral vaccines have been successful in overcoming this problem for both polio and typhoid and parenteral RV vaccines are now in development. This approach should be pursued for rotavirus vaccine as well because in low income countries where oral RV vaccines have been introduced and are only partially effective, RV remains the most common cause of diarrhea in children under 5 years. The ultimate control of RV diarrheal will likely require both oral and parenteral vaccines.