Variation in Rotavirus VaccineCoverage by Provider Location andSubsequent Disease BurdenLeila C. Sahni, MPHa, Jacqueline E. Tate, PhDb, Daniel C. Payne, PhD, MSPHb, Umesh D. Parashar, MBBS, MPHb,Julie A. Boom, MDa,c

abstract BACKGROUND: Rotavirus vaccines were introduced in the United States in 2006. Full-seriescoverage is lower than for other vaccines, and disease continues to occur. We examinedvariation in vaccine coverage among provider locations and correlated coverage with thedetection of rotavirus in children who sought treatment of severe acute gastroenteritis (AGE).

METHODS: Vaccine records of children enrolled in an AGE surveillance program were obtainedand children were grouped by the location that administered each child’s 2-month vaccines.Cases were children with laboratory-confirmed rotavirus AGE; controls were children withrotavirus-negative AGE or acute respiratory infection. Location-level coverage was calculatedusing $1 dose rotavirus vaccine coverage among controls and classified as low (,40%),medium ($40% to ,80%), or high ($80%). Rotavirus detection rates among patients withAGE were calculated by vaccine coverage category.

RESULTS: Of controls, 80.4% (n = 1123 of 1396) received $1 dose of rotavirus vaccine from68 locations. Four (5.9%) locations, including a NICU, were low coverage, 22 (32.3%) weremedium coverage, and 42 (61.8%) were high coverage. In low-coverage locations, 31.4% ofpatients with AGE were rotavirus-positive compared with 13.1% and 9.6% in medium- andhigh-coverage locations, respectively. Patients with AGE from low-coverage locations had3.3 (95% confidence interval 2.4–4.4) times the detection rate of rotavirus than patients with AGEfrom high vaccine coverage locations.

CONCLUSIONS: We observed the highest detection of rotavirus disease among locations with lowrotavirus vaccine coverage, suggesting that ongoing disease transmission is related to failureto vaccinate. Educational efforts focusing on timely rotavirus vaccine administration to age-eligible infants are needed.

WHAT’S KNOWN ON THIS SUBJECT: Uptake ofrotavirus vaccines has increased steadily sinceintroduction. Despite their demonstrated impact,rotavirus vaccine coverage is lower than forother vaccines recommended in infancy anddisease continues to occur.

WHAT THIS STUDY ADDS: We observed higherrotavirus detection rates among patients fromprovider locations with lower rotavirus vaccinecoverage; providers who do not offer rotavirusvaccine to age-eligible children may createpockets of susceptible children that serve asreservoirs of ongoing disease transmission.

aImmunization Project, Texas Children’s Hospital, Houston, Texas; bDivision of Viral Diseases, National Center forImmunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia; andcDepartment of Pediatrics, Baylor College of Medicine, Houston, Texas

Ms Sahni conceptualized and designed the study, coordinated and supervised data collection, anddrafted the initial manuscript; Dr Tate conceptualized and designed the study, carried out the initialanalyses, and reviewed and revised the manuscript; Drs Payne and Parashar conceptualized anddesigned the study, and reviewed and revised the manuscript; Dr Boom conceptualized anddesigned the study, and drafted the initial manuscript; and all authors approved the finalmanuscript as submitted.

The findings and conclusions in this report are those of the authors and do not necessarilyrepresent the official position of the Centers for Disease Control and Prevention.

www.pediatrics.org/cgi/doi/10.1542/peds.2014-0208

DOI: 10.1542/peds.2014-0208

Accepted for publication Nov 11, 2014

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Before the introduction of rotavirusvaccines in the United States,approximately 30% to 50% ofhospitalizations for severe acutegastroenteritis (AGE) in US childrenwere attributed to rotavirus.1–3 Twolive attenuated, oral vaccines arecurrently licensed and recommendedfor use in the United States: a 3-dosepentavalent vaccine (RotaTeq [RV5];Merck Vaccines, Whitehouse Station,NJ), licensed in 2006, and a 2-dosemonovalent vaccine (Rotarix [RV1];GlaxoSmithKline Biologicals,Rixensart, Belgium), licensed in 2008.The US Advisory Committee onImmunization Practices (ACIP)recommends that doses of eithervaccine be administered at 2 and4 months of age, with the third dose ofRV5 administered at 6 months of age.Specifically, ACIP states that the firstdose of either rotavirus vaccine maybe administered as early as 6 weeksof age and no later than 14 weeks6 days, whereas the final dose ofvaccine must be administered by8 months 0 days of age.4

Uptake of rotavirus vaccines hassteadily increased each year sinceintroduction, with national full-seriescoverage (either 2 or 3 dosesdepending on vaccine type) reaching67% in 2011.5 Concomitantly, theburden of rotavirus AGE has declineddramatically in the years aftervaccination, with studies estimatinga 60% to 89% reduction inhospitalizations due to rotavirusamong children ,5 years of age.2,6,7

Despite the demonstrated impact ofrotavirus vaccines, full-seriescoverage 5 years after introduction ofrotavirus vaccine remains lower thanfor other vaccines recommended at 2,4, and 6 months of age, for whichcoverage is 93% to 95%.5 There areseveral reasons this discrepancy mayexist: the narrow age ranges duringwhich the first and final doses ofrotavirus vaccine may beadministered,4 lingering safetyconcerns after withdrawal of theRotaShield vaccine in 1999,8–10

hesitancy about use of a new live

attenuated oral vaccine, and issuesregarding vaccine cost and insurancereimbursement.9,10

Texas Children’s Hospital (TCH)conducts active surveillance forsevere AGE as part of the NewVaccine Surveillance Network.11

During routine surveillance, weanecdotally noticed that a highproportion of rotavirus-positive caseswere occurring among patients froma small number of individual providerlocations. As vaccine purchasing andadministration policies are typicallydetermined at the provider level, wehypothesized that the high proportionof rotavirus-positive cases observedat some provider locations could beassociated with lower rotavirusvaccine coverage at these sites. Toexplore this further, we examined thevaccine records of children enrolledin our routine AGE and acuterespiratory infection (ARI)surveillance initiative to evaluatevariation in rotavirus disease byvaccine coverage at each location andcorrelated coverage with thedetection of rotavirus in children whosought treatment of severe AGE.

METHODS

At the emergency department of TCHin Houston, we conducted activesurveillance for children ,5 years ofage who sought treatment of AGE($3 loose stools and/or $1 episodeof vomiting) during the months ofhighest rotavirus activity, November2009 through June 2010(“2009–2010 rotavirus season”) andNovember 2010 through June 2011(“2010–2011 rotavirus season”).Patients with AGE were consented forenrollment and fecal specimens werecollected within 14 days of illnessonset (82% of specimens werecollected within 7 days of illnessonset) to test for rotavirus by usinga commercial enzyme immunoassay(Premier Rotaclone; MeridianBiosciences, Inc, Cincinnati, OH). Weconducted a case-control assessmentof rotavirus vaccine effectiveness in

conjunction with surveillanceactivities. Cases were children withlaboratory-confirmed rotavirusgastroenteritis who were identifiedthrough AGE surveillance. Twodistinct control groups were used:children identified through AGEsurveillance who had rotavirus-negative AGE and children with ARIwho were identified and enrolledduring the AGE surveillance period toserve as controls for the vaccine-effectiveness assessment. Contactinformation for up to 3 immunizationproviders was obtained from theparent/guardian during enrollmentfor all children, and permission wasobtained to contact these providersfor vaccine information. Permissionwas also obtained to search the Texasstatewide immunization informationsystem, ImmTrac. Results of the case-control evaluation are presentedelsewhere.12

This assessment used the cases andcontrols from the vaccine-effectiveness assessment. Rotavirusvaccine information, including date ofadministration, dose number, vaccinetype, and name of the administeringprovider location was abstractedfrom vaccine records for cases andcontrols. Provider location wasdefined as $1 medical providerstreating children at the same physicallocation. Children were grouped bythe location that administered eachchild’s 2-month vaccines, andcharacteristics (public, private,hospital affiliation, multiple locations)describing each location wereobtained. The 2-month visit wasselected because it is unlikely thatchildren receiving vaccines atsubsequent visits would be age-eligible to receive rotavirus vaccine ifthe first dose had not previously beenadministered at the 2-month visit;therefore, the burden of rotavirusvaccine series initiation lies with theprovider of 2-month vaccines. Ifneeded, parents were recontacted byphone to confirm the providerlocation that administered 2-monthvaccines.

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Children for whom a vaccine recordcould not be obtained, whose providerof 2-month vaccines could not beidentified, who were vaccinated outsidethe Greater Houston area, who were.2 months of age but had received no2-month vaccines, who were too youngto have received rotavirus vaccine(,42 days of age), or who were bornbefore rotavirus vaccine licensure (bornbefore April 1, 2006) were excludedfrom analyses (Fig 1). Analyses were

restricted to provider locations fromwhich $10 controls were enrolledduring the 2-year study period to avoidartificial skewing of coverage based ona small number of subjects; caseswere excluded from analyses if theyreceived their 2-month vaccines froma location with ,10 controls enrolled.For children with multiple hospitalvisits during the 2 combinedsurveillance seasons, only the first visitwas included.

For each provider location fromwhich $10 controls were enrolled,vaccine coverage with $1 dose of anyrotavirus vaccine was calculated bydividing the number of controls whoreceived at least 1 dose of rotavirusvaccine by the total number ofcontrols enrolled from that location.We examined the distribution ofvaccine coverage levels by individualprovider location and createda 3-level categorical vaccine coverage

FIGURE 1Flow diagram of participant inclusion in analysis for rotavirus-positive cases, and rotavirus-negative AGE and ARI controls. RV+, rotavirus-positive;RV–, rotavirus-negative.

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variable. Provider locations with$1 dose coverage of ,40% wereconsidered low coverage, providerlocations with coverage of $40% to,80% were considered mediumcoverage, and those with coverage$80% were considered highcoverage provider locations. Thecutpoints for the coverage groupswere selected a priori. However, insensitivity analyses, numerouscutpoints for inclusion of thepractices in the low-coverage groupwere examined.

Categorical variables were comparedby using x2 analyses and medianswere compared by using theWilcoxon rank-sum test. Ageneralized linear model withPoisson family, log link, and robusterror variance was used to comparethe rotavirus detection rates in thedifferent coverage groups. Allanalyses were performed by usingSAS 9.3 (SAS Institute, Inc, Cary, NC).

This study was reviewed andapproved by institutional reviewboards at Baylor College of Medicineand Texas Department of State HealthServices. Informed consent was

obtained from participants’ parents/guardians.

RESULTS

A total of 2197 children with AGE and1523 children with ARI were enrolledduring the 2009–2010 and2010–2011 rotavirus seasons. Afterexcluding ineligible children andrestricting analyses to providerlocations from which $10 controlswere enrolled, a total of 100 rotavirus-positive cases, 725 rotavirus-negativeAGE controls, and 670 ARI controlswere included in this assessment(Fig 1). Of the 1395 included controlchildren (725 rotavirus-negative AGEand 670 ARI controls), 80.4%(n = 1122) had received $1 dose ofrotavirus vaccine and were vaccinatedby 68 different locations. Four (5.9%)locations, including a NICU, wereclassified as low coverage ($1 dosecoverage of ,40%), 22 (32.3%)locations were classified as mediumcoverage ($1 dose coverage of $40%to ,80%), and 42 (61.8%) wereclassified as high coverage ($1 dosecoverage of $80%) (Table 1). Allprovider locations in each of the

coverage categories were pediatriconly (no family physicians) and mostwere affiliated with academicinstitutions (Table 1). Within eachcoverage category, the proportion ofAGE cases that were due to rotavirusvaried (Fig 2).

The proportion of children age-eligible to have received a completeseries ($8 months of age) wassimilar across coverage categories(74% in low- and medium-coveragelocations and 70% in high-coveragelocations). The distribution ofrotavirus vaccine doses amongchildren age-eligible for a full seriesvaried by provider location coveragecategory. In low-coverage locations,12.5% (6 of 48) of these age-eligiblechildren were fully vaccinated(2 doses of RV1 or 3 doses of RV5)compared with 49.3% (184 of 373) ofchildren at medium-coveragelocations and 67.9% (395 of 582) ofchildren at high-coverage locations.Conversely, 87.5% (42 of 48) ofchildren age-eligible to have receiveda full series in low-coverage locationshad received no doses of rotavirusvaccine, compared with 29.5%(110 of 373) of children in medium-coverage locations and 10.3% (60 of582) of children in high-coveragelocations (Table 2).

We observed differences in the age ofvaccinated and unvaccinated controlsacross all coverage categories.Children who had received $1 doseof rotavirus vaccine were youngerthan children who had received nodoses of vaccine (12.9 vs 22.5 months[P , .001], respectively). The age ofvaccinated children in low-coverageprovider locations was similar to theages of those belonging to medium-and high-coverage locations(Table 2).

In low-coverage locations, rotaviruswas detected in 31.4% of patientswith AGE compared with 13.1% and9.6% in medium- and high-coveragelocations, respectively. From thePoisson model, patients with AGEfrom low-coverage locations had 3.3

TABLE 1 Summary of AGE Case and Control Enrollment and Type of Provider Locations byCoverage Level Category

Rotavirus Vaccine Coverage Levels in Controls

,40% $40% to ,80% $80%

No. of provider locations 4 22 42Median no. of AGE cases per provider

location (range)14.5 (6–16) 9.5 (3–33) 9.5 (4–43)

Median % of rotavirus-positive casesper provider location (range)

33.3 (25.0–35.7) 12.4 (0.0–29.6) 9.2 (0.0–26.7)

Median no. of controls per providerlocation (range)

17.5 (11–19) 19 (10–66) 16 (10–62)

Median % of controls with $1dose of rotavirus vaccineper provider location (range)

8.5 (0.0–36.4) 74.7 (40.0–78.8) 90.5 (80.0–100.0)

Type of provider location n (%) n (%) n (%)Public providersHospital affiliated — 2 (9.1) —

Local health department — 3 (13.7) 2 (4.8)Federally qualified health center — 1 (4.5) 1 (2.3)

Private providersHospital affiliated — 7 (31.8) 15 (35.7)Single location 3 (75.0) 8 (36.4) 22 (52.4)Multiple locations — 1 (4.5) 2 (4.8)

NICU 1 (25.0) — —

—, no provider locations of this type in this coverage level.

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(95% confidence interval 2.4–4.4)times the detection rate of rotavirusthan that of patients with AGE in thehigh vaccine coverage locations.There was no significant difference inrotavirus-detection rates betweenchildren with AGE in the medium-and high-coverage provider locations(Incidence Rate Ratio 1.4 [95%confidence interval 0.9–2.1]). Resultswere consistent across rotavirusseasons when each season wasanalyzed separately. In sensitivityanalyses, we repeated the analyseswith numerous different cutpoints forthe low-coverage category but noimpact was observed on the results.

DISCUSSION

We examined rotavirus vaccinationcoverage at high-volume pediatricprovider locations whose patients

used the TCH emergency departmentduring the 2-year study period. Of the68 locations identified, 42 (62%) hadhigh rotavirus vaccine coveragelevels, whereas 22 (32%) hadmedium rotavirus vaccine coveragelevels, and 4 (6%) had low rotavirusvaccine coverage rates. Three of the4 low-coverage locations are privatepediatric primary care offices,whereas the fourth locationrepresents children hospitalized ina NICU at the time of 2-monthvaccinations. Although only 4 (6%) ofthe 68 provider locations included inthis analysis were designated as lowcoverage (,40%), 16% (n = 16 of100) of all rotavirus-positive childrenenrolled during the 2-year studyperiod received their 2-monthvaccinations at 1 of these locations.Furthermore, a tendency toward

increasing detection of rotavirus inpatients with AGE with decreasingprovider -level rotavirus vaccinecoverage was observed, with childrenfrom low-coverage locations havingmore than 3 times higher detectionrates of rotavirus than in childrenfrom high-coverage locations.Collectively, these findings indicatethat failure to vaccinate iscontributing, at least in part, to thelower but persistent burden ofrotavirus AGE in the post–rotavirusvaccine era.

As a detailed characterization of theprovider locations and the vaccineattitudes of parents treated at theselocations was not an objective of thisstudy, the reason for the low rotavirusvaccine coverage among some sites isunclear. However, the reasons for lowrotavirus vaccine coverage among

FIGURE 2Proportion of rotavirus-positive participants with AGE by provider-level coverage with $1 dose of rotavirus vaccine.

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NICU children are identifiable andcomplex. Because rotavirus vaccine isa live, attenuated orally administeredvaccine and shedding of vaccine virusis known to occur afteradministration,13–16 ACIPrecommends vaccination of age-eligible infants at the time of NICUdischarge and not duringhospitalization.4 An assessment ofrotavirus vaccination status amongvery low birth weight infants at NICUdischarge found that .50% of infantsincluded in the assessment were age-eligible to have received rotavirusvaccine at discharge.17 Although thisassessment was conducted in a singleNICU, it is reasonable to expect thatmany infants hospitalized in otherNICUs also would be age-eligible toinitiate rotavirus vaccine at discharge.Infants discharged from a NICU arefrequently underimmunized for all2-month vaccinations18; specific torotavirus vaccine, we believe that thisunderimmunization may beexacerbated by the logisticalchallenges of vaccine administration atthe time of NICU discharge and notduring hospitalization. If rotavirusvaccine is not given during NICUhospitalization or at discharge,

pediatricians in the community mayfail to realize this, may presume thatthe vaccine had been omitted fora specific reason, or may have doubtsabout administering vaccine toa fragile, medically complex infant.Unfortunately, failure to vaccinatethese vulnerable infants may result insevere disease requiring medicalattention.19,20 Given the current,explicitly defined ACIPrecommendation, infants hospitalizedin a NICU for $15 weeks miss thewindow of eligibility to receiverotavirus vaccine.

Unvaccinated children in this studywere older than children who hadreceived $1 dose of vaccine. This isnot surprising, given the increasinglevel of rotavirus vaccine coverageover the years. This difference in agebetween vaccinated and unvaccinatedchildren is smallest among childrenat high-coverage locations, whichsuggests that these providers mayhave adopted rotavirus vaccinerecommendations earlier thanproviders at low- and medium-coverage locations. Similarly, high-coverage locations had the smallestproportion of unvaccinated childrenamong those age-eligible to have

received a full series of rotavirusvaccine compared with the medium-and low-coverage sites.

This study has several limitations.First, children were assigned to theprovider location where their 2-monthvaccines were administered by usinginformation obtained from theirvaccine record. If the child’s 2-monthvaccines were documented ashistorical data but not indicated assuch either on the record or to ourstudy staff, a miscategorization mayhave occurred. We believe that anysuch miscategorization would havebeen equally likely to occur among alllocations, regardless of the coveragecategory to which they were assigned.Second, because provider locationswere required to have $10 controlsenrolled during the 2-year studyperiod, smaller locations and sites thatinfrequently had children visit TCHwere excluded from analysis. Thisresulted in the elimination of 91rotavirus-positive cases and 979combined rotavirus-negative AGE andARI controls; however, children fromincluded and excluded practices wereof similar ages and had similarrotavirus vaccine coverage. Our smallsample size precluded some statisticalanalyses; however, this assessmentwas exploratory in nature and suggeststhe need for larger future studies toconfirm our findings. Third, we did notcontrol for provider location size.Given the large number of locationsincluded in this study, it was notfeasible to obtain information aboutthe size of each location’s active patientpopulation. This assessment wasconceived after patient enrollment hadconcluded, and information about eachlocation’s patient population sizeduring the study period was notobtained. Attempting to obtainretrospective estimates of eachlocation’s active patient populationwould likely be inaccurate. For thesereasons, attack rates were calculatedusing the total number of childrentreated for AGE at TCH. If either theproportion of children with medicallyattended AGE at TCH varied or the

TABLE 2 Characteristics of AGE Cases and Controls by Provider Location Coverage Level Category

Rotavirus Vaccine Coverage Levels in Controls

,40% $40% to ,80% $80%

Total no. of AGE cases 51 274 500No. of rotavirus-positive cases 16 36 48% of rotavirus-positive cases 31.4 13.1 9.6Total no. of controls 65 501 829No. of controls with $1 dose of rotavirus vaccine 7 363 752% of controls with $1 dose of rotavirus vaccine 10.8 72.5 90.7No. of (%) doses of rotavirus vaccine

received among children $8 mo of agea

0 42 (87.5) 110 (29.5) 60 (10.3)1 0 (0.0) 31 (8.1) 41 (7.0)2 1 (2.1) 49 (13.1) 86 (14.8)3 5 (10.4) 183 (49.1) 395 (67.9)Total 48 (100.0) 373 (100.0) 582 (100.0)

Median age in mo of controls (range) 19.5 (2.0–55.4) 14.9 (2.0–58.4) 13.1 (2.0–61.2)Median age in mo of vaccinated controls (range) 10.5 (6.2–29.8) 13.3 (2.1–54.5) 12.7 (2.0–59.9)Median age in mo of unvaccinated controls (range) 22.0 (2.0–55.4) 26.1 (2.0–58.4) 20.7 (2.1–61.2)a All except 4 children received RV5. Of the 4 children who received RV1, 2 received 1 dose and 2 received 2 doses. One ofthe 2-dose RV1 recipients was from a low-coverage location (,40%) and the other from a medium-coverage location($40% to ,80%). Thus, 6 (12.5%) of 48 children in low-coverage locations, 184 (49.3%) of 373 children in medium-coverage locations, and 395 (67.9%) of 582 of children in high-coverage locations were fully vaccinated.

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proportion of children who acquiredAGE varied by location, this may haveinfluenced our results. Similarly, weestimated provider-level coveragerates from rotavirus-negative patientswith AGE and ARI controls who soughttreatment at TCH. If these vaccinatedand unvaccinated childrendifferentially sought care at TCH orwere not representative of the largerpatient population, then our resultsmay be biased. Fourth, because we didnot evaluate parental vaccine beliefsand attitudes, it was not possible todetermine whether children did notreceive rotavirus vaccine because ofparent request or because of providervaccination practices. Excludingchildren who had received no vaccinesother than a birth-dose of hepatitisB vaccine could have biased our findingsin either direction. If these childrenhad actually received rotavirus vaccineat 2 months of age, this would haveresulted in an underestimation ofrotavirus vaccine coverage. Conversely,nonreceipt of rotavirus vaccinebecause of parental refusal would haveoverestimated rotavirus vaccinecoverage. Given the small number ofchildren in this assessment for whomdocumentation of only hepatitis B

vaccine was obtained (n = 17) and therelatively low rate of vaccineexemptions in Texas,21 it is unlikelythat this had a major impact on ourfindings. Fifth, most included providerlocations were affiliated with academicinstitutions and may not berepresentative of all provider sites inthe greater Houston area. Similarly,because this study was conducted ata single site, it may not berepresentative of rotavirus vaccinecoverage and disease rates in theUnited States.

CONCLUSIONS

In this study, we observed higherdetection rates of rotavirus amongpatients with AGE from providerlocations with lower rotavirusvaccine coverage, including inhospitalized infants who werescheduled to receive their 2-monthvaccines in a NICU. These findingssuggest that the failure of providersto consistently offer rotavirus vaccineto age-eligible children may result insusceptible children who serve asreservoirs of ongoing diseasetransmission. Initiating rotavirusvaccination at the time of NICU

discharge has logistical challengesand infants may no longer be age-eligible, thereby leaving thesevulnerable infants unvaccinated.Studies to assess the potential risksof nosocomial transmission ofrotavirus vaccine strains in theNICU will help weigh the risks andbenefits of vaccinating infants in theNICU. Educational efforts targetingvaccine providers, including NICUphysicians and nurses, should focuson the importance of administrationof rotavirus vaccine to every age-eligible child. Furthermore, local andstate health departments should usetheir immunization informationsystems to identify providerlocations where additional educationabout the importance of rotavirusadministration may be needed.

ACKNOWLEDGMENTS

We thank the families whoparticipated in this assessment; KatieJones and M. Helena Espinosafor collecting data; Marcia Rench forrotavirus testing; Phil Smith forinformation about national rotavirusvaccine coverage; and Virginia Moyer,MD, MPH, for editorial comments.

Address correspondence to Leila C. Sahni, MPH, 1102 Bates Ave, Ste 1550, Houston, TX 77030. E-mail: lcsahni@texaschildrens.org

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

Copyright © 2015 by the American Academy of Pediatrics

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

FUNDING: Ms Sahni and Dr Boom were supported by a Centers for Disease Control and Prevention grant awarded to the Texas Department of State Health Services

(CDC-RFA-CI07-70405ARRA09: Strengthening the Evidence Base: Epidemiology and Laboratory Capacity for Infectious Diseases [ELC] Rotavirus Vaccine Effectiveness)

and a subsequent contract between the Texas Department of State Health Services and Texas Children’s Hospital.

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

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DOI: 10.1542/peds.2014-0208 originally published online January 12, 2015; 2015;135;e432Pediatrics 

BoomLeila C. Sahni, Jacqueline E. Tate, Daniel C. Payne, Umesh D. Parashar and Julie A.

Disease BurdenVariation in Rotavirus Vaccine Coverage by Provider Location and Subsequent

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DOI: 10.1542/peds.2014-0208 originally published online January 12, 2015; 2015;135;e432Pediatrics 

BoomLeila C. Sahni, Jacqueline E. Tate, Daniel C. Payne, Umesh D. Parashar and Julie A.

Disease BurdenVariation in Rotavirus Vaccine Coverage by Provider Location and Subsequent

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ISSN: 1073-0397. 60007. Copyright © 2015 by the American Academy of Pediatrics. All rights reserved. Print the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois,has been published continuously since 1948. Pediatrics is owned, published, and trademarked by Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it

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