416 www.thelancet.com/infection Vol 14 May 2014 Review Rotavirus vaccination in Europe: drivers and barriers N Parez, C Giaquinto, C Du Roure, F Martinon-Torres, V Spoulou, P Van Damme, T Vesikari Rotavirus gastroenteritis is a vaccine-preventable disease that confers a high medical and economic burden in more developed countries and can be fatal in less developed countries. Two vaccines with high efficacy and good safety profiles were approved and made available in Europe in 2006. We present an overview of the status of rotavirus vaccination in Europe. We discuss the drivers (including high effectiveness and effect of universal rotavirus vaccination) and barriers (including low awareness of disease burden, perception of unfavourable cost-effectiveness, and potential safety concerns) to the implementation of universal rotavirus vaccination in Europe. By February, 2014, national universal rotavirus vaccination had been implemented in Belgium, Luxembourg, Austria, Finland, Greece, Luxembourg, Norway, and the UK. Four other German states have issued recommendations and reimbursement is provided by sickness funds. Other countries were at various stages of recommending or implementing universal rotavirus vaccination. Introduction Rotavirus gastroenteritis is a disease that can be prevented by vaccination. Two vaccines, RotaTeq (Merck and Co, Whitehouse Station, NJ, USA; Sanofi Pasteur MSD, Lyon, France) and Rotarix (GlaxoSmithKline, Rixensart, Belgium), are available in Europe. Both are live, attenuated rotavirus vaccines given orally that have shown high efficacy and good safety profiles in large clinical trials. These findings have been confirmed in clinical practice, although the vaccines have shown lower efficacy in field trials in less developed countries. 1–8 Rotarix is a monovalent human vaccine originating from a G1P[8] strain. RotaTeq is a pentavalent vaccine containing five human-bovine reassortant strains (G1, G2, G3, G4, and P1A[8]). 9 Both vaccines aim to prime broad immune responses followed by progressively broader protection, developing through successive natural rotavirus infections. 10 Because the vaccines became available in Europe in 2006, universal rotavirus vaccination has been imple- mented in Austria, Belgium, Luxembourg, Finland, Greece, Luxembourg, Norway, and the UK. Several other countries are at various stages of issuing national recommendations or integrating rotavirus vaccination into their national immunisation programmes. We provide an overview of the status of rotavirus vaccination in Europe in February, 2014, and discuss the drivers and barriers to the implementation of universal rotavirus vaccination. Status of rotavirus vaccination in 2014 The inclusion of vaccination with either rotavirus vaccine in national immunisation programmes has been recommended worldwide by WHO since 2009. 8 Since 2006, the Centers for Disease Control and Prevention Advisory Committee on Immunisation Practices has recommended routine rotavirus vaccination of infants in the USA. 11 The same year, vaccination was implemented in this group. Universal rotavirus vaccina- tion was also introduced in Australia in 2007 and in almost 20 American countries, including Brazil (2006) and Mexico (2007). 12,13 In Europe, evidence-based recommendations for uni- versal rotavirus vaccination were published in 2008 by the European Society for Paediatric Infectious Diseases and the European Society for Paediatric Gastroenterology, Hepatology and Nutrition. 14 Despite these recom- mendations, the present status of universal rotavirus vac- cination (table) and vaccination coverage (figure) varies greatly across Europe. Countries with high vaccination coverage High vaccination coverage is defined as more than 90%. The Austrian Advisory Committee on Immunisation recommended universal rotavirus vaccination in Austria in 2006, and it was introduced in 2007, with full reimbursement for the vaccines. 15 Local epidemiological data showing a high disease burden in Austrian children were an important driver for the implementation of universal rotavirus vaccination. 16 On the basis of the recommendations from the Superior Health Council of Belgium, rotavirus vaccination has been offered to all Belgian children with the other infant vaccines of the national immunisation programme since 2006. 15,17 Rotavirus vaccines have to be prescribed by a private doctor; the cost is met by a co-payment system (in 2012–13, €11·30 per dose by the parent, and the rest by health-care insurance). Paediatricians in the National Health Council were important proponents of the integra- tion of rotavirus vaccination in the Belgian national immunisation programme. When rotavirus vaccines became available in Europe in 2006, rotavirus vaccination was recommended by the Superior Hygiene Council (now the Superior Council for Communicable Diseases) of Luxembourg and was included in the national immunisation programme, free of charge. 15 This decision was based on the expected reduction in morbidity, use of health-care resources, and cost. The Ministry of Health fully funds and supplies the vaccines. After the 2007 recommendations of the Finnish National Public Health Institute, the National Health Authorities of Finland introduced rotavirus vaccination in the national immunisation programme in 2009, with Lancet Infect Dis 2014; 14: 416–25 Service de Pédiatrie, Hôpital Louis Mourier, Colombes, France (N Parez PhD); Department of Paediatrics, University of Padua, Padua, Italy (Prof C Giaquinto MD); PHOCUS Services Ltd, Basel, Switzerland (C Du Roure PhD); Pediatric Infectious Diseases and Vaccines Unit, Area Integrada de Pediatría, Hospital Clínico Universitario de Santiago and Genetics, Vaccines, Infections and Pediatrics Research Group (GENVIP), Healthcare Research Institute of Santiago, University of Santiago, Spain (F Martinon-Torres PhD); Aghia Sophia Children’s Hospital, Athens University School of Medicine, Athens, Greece (V Spoulou PhD); Centre for the Evaluation of Vaccination, Vaccine & Infectious Disease Institute, Faculty of Medicine and Health Sciences, University of Antwerp, Belgium (Prof P Van Damme PhD); and University of Tampere Medical School, Tampere, Finland (Prof T Vesikari MD) Correspondence to: Dr N Parez, Service de Pédiatrie, Hôpital Louis Mourier, 92701 Colombes, France nathalie.parez@gmail.com