Performance of Oral Rotavirus Vaccines in Low- and Middle-Income Settings: Current Evidence, Persistent Gaps and Future Directions.

Oral, live-attenuated rotavirus vaccines (ORVs) have significantly reduced severe diarrheal disease and deaths; however, vaccine performance in low- and middle-income countries (LMICs) remains lower than in high-income countries. With increasing global use, real-world data now provide important insights into strategies to improve vaccine impact in these settings. This review summarizes current evidence on the effectiveness and impact of ORVs in LMICs, with a focus on approaches to optimize performance, including alternative dosing schedules, booster doses in late infancy, and mixed vaccine regimens. Evidence on vaccine interchangeability offers practical solutions for countries facing supply disruptions and financial constraints. The review also highlights the growing importance of economic sustainability, particularly in the context of transitions from external funding support. Despite lower efficacy, ORVs continue to provide substantial public health benefits in LMICs. Sustained impact will depend on strengthening programme delivery, ensuring stable vaccine supply, and advancing next-generation vaccines. Continued evaluation of effectiveness, cost, and implementation strategies will be critical to maximizing long-term benefits in high-burden settings.