Josephine van Dongen

8 Summary and general discussion 197 In the RIVAR study the full safety-effectiveness-implementation spectrum of rotavirus vaccination for infants with MRC was evaluated.Therefore, for this specific patient population, guided recommendations can be made. Non-specific effects of rotavirus vaccination are ignored in this recommendation, because these could not be confirmed in our study but we acknowledge that fur ther research is required. Considering the combined (cost-) effectiveness, safety and feasibility results I would advise a universal rotavirus vaccination strategy excluding premature infants below 32 weeks of gestation and premature infants with comorbidities. At high vaccination coverage, this strategy could yield sufficient indirect effectiveness (herd effect), and reduction in nosocomial infections for the extreme vulnerable medical risk infants, as well as substantial reductions in rotavirus disease in the total infant population, resulting in cost and healthcare benefit.The existing national immunization program infrastructure can be used, guaranteeing quality of parent counseling and high uptake in the population. Because the most extremely vulnerable infants with MRC are excluded, administration within age restrictions of rotavirus vaccination will generally be feasible at well-baby clinics. Rotavirus vaccine effectiveness in healthy premature and term infants with congenital (gastrointestinal) pathology has been studied satisfactory, even though newer studies in the current epidemiology landscape are needed. Figure 2 Rotavirus vaccine development pipeline. Based on Burke et al - Curr Opin Infect Dis 2019