Elsevier

Vaccine

Volume 23, Issues 17–18, 18 March 2005, Pages 2304-2310
Vaccine

Bacterial otitis media: a vaccine preventable disease?

https://doi.org/10.1016/j.vaccine.2005.01.023Get rights and content

Abstract

Otitis media (OM) is the most common childhood illness for which medical advice is sought. Whilst the disease rarely results in death, there is a significant level of morbidity and economic burden on the community. Although the causes of OM are multifactoral, bacterial and viral infections are the single most important cause. Bacteria responsible for infections of the middle ear are predominantly, nontypeable Haemophilus influenzae, Streptococcus pneumoniae and Moraxella catarrhalis. Antibiotics have been widely used to treat children who present to a medical clinic with OM. However, given the high prevalence of this disease and the increasing incidence of microbial resistance to antibiotics, there is a need to develop alternative therapeutic strategies such as vaccination. Pneumococcal polysaccharide vaccination has produced disappointing results for effectiveness in preventing OM and there is evidence of an increased incidence of disease due to non-vaccine serotypes. An efficacious vaccine for bacterial OM would require combining protective protein antigens from all three causative bacteria. A combined bacterial–viral vaccine formulation would produce the most profound and sustained impact on reducing the global incidence of OM.

Introduction

Otitis media (OM) is one of the most frequent childhood diseases, the primary reason for a child under the age of 3 years of age to visit a general practitioner [1] and the most common indication for the prescription of antibiotics [2]. In the mid 1990s, in USA, it was estimated that there were 14 million episodes of OM per annum in children under the age of 5 and that the cost of treatment was in excess of $US5 billion [3]. Similar estimates are most likely to describe OM disease burden in other developed countries. In developing countries where the burden of respiratory disease is thought to be in the order of 10 times greater, compared with developed nations, the burden of suffering due to OM would be predictably higher and, without ready access to medical treatment, the serious and long term sequelae greater. The excessive use and indeed the necessity of antimicrobial therapy in OM remains controversial [2]. With the increase in the number of bacterial pathogens resistant to many antimicrobial agents there has been a corresponding increase in suppurative complications [4]. Over the past 30 years, there have been numerous studies examining the complex relationship of recurrent otitis media in early life to hearing loss and potential impact on language and academic achievement [5]. Because of the human and economic costs associated with OM, there is great interest in developing intervention strategies to manage this challenging disease. The burden of disease in many at risk cohorts meets the World Health Organisation's (WHO) criteria as a massive public health problem [6].

Section snippets

Otitis media

OM is the general term for a continuum of related middle ear diseases. There are three main categories of OM of which, there is no accepted and standard definition amongst health professionals. Acute otitis media (AOM) is generally defined as the presence of middle ear effusion accompanied with the rapid onset of one or more signs or symptoms of inflammation in the middle ear, such as otalgia, otorrhea, fever and irritability. Otitis media with effusion (OME) is a condition without signs or

Epidemiology

In the USA, approximately 80% of children have at least one episode of AOM by 3 years of age, with a peak incidence between 6 and 18 months [9], [10]. Recurrent AOM is generally diagnosed when 3 or more episodes of AOM have occurred within a period of 6 months or 4 or more episodes in 12 months. It commonly affects 10–20% of children by 12 months of age. By 7 years of age, almost 40% of children have had 6 or more episodes of AOM [10]. By their first birthday, >50% of children have experienced

Risk factors

An immature immune system and Eustachian tube is thought to account for the predisposition of infants and young children to OM. However, some children are at risk of severe and recurrent disease. It is important to identify risk factors for OM in these children as they can inform strategies for early prevention and intervention. To this end, much work has been done to understand the factors that have been associated with AOM, such as: microbial agents (bacterial and viral); anatomic factors

Antibiotics and other chemotherapies

From a meta-analysis of 21 studies up until 1993, Williams and colleagues [39] concluded that antibiotic treatment had a beneficial but limited effect on recurrent OM and short term resolution on OME. A more recent Cochrane Review [40] of 10 trials concluded that antibiotics shortened the duration of AOM. Neither analysis provided evidence that antibiotic treatment altered the course of otitis disease in children. A recent Clinical Practice Guideline: Otitis Media with Effusion [11] also

Vaccination

OM is a polymicrobial disease in which complex relationships between the different bacteria and viruses have been described and hypothesised. In fact the complex nature of these interactions are poorly understood. With this background and the large number of predisposing risk factors the concept of developing a successful vaccine to protect children against OM is indeed a challenge.

For a vaccine formulation to be efficacious for OM it must: contain one or more antigens from each of the

Relief from the misery of otitis media

Millions of children are afflicted with the misery of OM across the globe. The disease is complex and multifactorial in aetiology. Interventions include widespread use of antibiotics, invasive surgical procedures, and risk reduction strategies. However, none of these interventions are likely to result in a sustained global reduction in the incidence of OM. The most successful intervention strategy for controlling infectious diseases has been immunisation. Whilst immunisation against what are

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