Up-To-Date Vaccinations May Help Your Child Stay In School

The beginning of the school year is the perfect time to make sure your child has his or her most recent immunization, especially vaccinations that can help prevent meningitis and middle ear infections (otitis media).

Childhood vaccination can stem millions of illnesses and prevent thousands of deaths. While eight out of every ten children in the United States are fully vaccinated, checking your child’s health records is the perfect preparation for the back-to-school time period.

Your child’s academic success is linked to their ability to stay healthy and in school. Nearly 100 percent of American children will suffer from otitis media by the age of five, accounting for over 25 million visits to the doctor’s office each year.

This year, ask your otolaryngologist about what vaccines are appropriate for your child. Depending on your child’s health history, this may include:

The conjugated pneumococcal vaccine

–This shot-administered vaccine prevents diseases caused by seven of the most common types of pneumococcal bacteria. It is safe and effective; the Centers for Disease Control and Prevention and the American Academy of Pediatrics recommended the vaccine for infants and toddlers under the age of five. It protects against serious forms of the disease up to 97 percent of the time, depending on the person. The vaccine’s side effects, which are usually minor and temporary, include some redness, swelling or tenderness from the injection, and a mild fever. Serious side effects, including allergic reactions, are quite rare.

Haemophilus influenzae (NTHi) and Moraxella catarrhalis vaccine

–These protect against two other common bacteria that cause ear and sinus infections, nontypeable Haemophilus influenzae (NTHi) and Moraxella catarrhalis. Recently, the National Institutes of Health has issued a license for the first clinical trials for a nontypeable Haemophilus influenzae (NTHi) vaccine. Vaccines to prevent viral infections like the flu that can eventually lead to ear infections should be considered for children with recurring ear infections. These vaccines are usually administered in the fall.

Resistant Biofilm Bacteria, Chronic Middle Ear Infections And Antibiotics Linked

A groundbreaking study makes a definitive statement against the use of antibiotics to treat children with Chronic Otitis Media.

Direct evidence of bacterial biofilms has been found on the middle ear tissue of children who suffer from chronic ear infections, according to a study published today in the Journal of the American Medical Association (JAMA) by researchers from the Allegheny Singer Research Institute (ASRI) at Allegheny General Hospital in Pittsburgh, the Medical College of Wisconsin and Children’s Hospital of Wisconsin in Milwaukee.

Biofilms are antibiotic resistant colonizations of bacteria that attach to surfaces and form a slime-like barrier that acts as a formidable defense mechanism, protecting the bacteria from eradication.

The discovery of biofilms in the setting of chronic otitis media represents a landmark evolution in the medical community’s understanding about a disease that afflicts millions of children world-wide each year and further endorses the emerging biofilm paradigm of chronic infectious disease, said Garth Ehrlich, Ph.D., principal investigator and executive director of the ASRI Center for Genomic Sciences.

Over the past ten years, Dr. Ehrlich and J. Christopher Post, M.D., Ph.D., FACS, an Allegheny General Hospital pediatric ear specialist and medical director of the Center for Genomic Sciences, have pioneered the biofilm theory to explain the persistence of chronic ear infections. In 2002, the team published in JAMA (Apr 2002; 287: 1710 – 1715) the first animal evidence of biofilms in the middle ear, setting the stage for the current clinical investigation.

According to co-investigator Joseph E. Kerschner M.D., “Today’s study completely alters the concept about how physicians should approach the treatment of children with otitis media. This historic finding sheds new light on the decreasing efficacy of antibiotics in treating kids with ear infections and has serious implications about the future direction of therapeutic research.” Dr. Kerschner is associate professor of otolaryngology at the Medical College and chief of pediatric otolaryngology at the College and Children’s Hospital of Wisconsin, a major teaching affiliate of the College.

“Nearly all of the children in our study who suffered from chronic otitis media tested positive for biofilms in the middle ear, even those who were asymptomatic.

It appears that in many cases recurrent disease stems not from re-infection as was previously thought and which forms the basis for conventional treatment, but from a persistent biofilm,” Ehrlich said.

“Given that bacteria living in biofilms are metabolically resistant to antibiotics, this study makes a definitive, scientifically-based statement against the use of these drugs to treat children with chronic ear infections. It simply does not help the child and increases the risk of breeding more resistant strains of bacteria,” he said.

Characterized as either an acute or chronic disease, otitis media (OM) is the most common illness for which children visit a physician, receive antibiotics or undergo surgery in the United States. There are two subtypes of chronic OM: recurrent OM (ROM) is diagnosed when children suffer repeated infections over a span of time and during which clinical evidence of the disease resolves between episodes, and chronic OM with effusion is diagnosed when children have persistent fluid in the ears that lasts for months in the absence of any other symptoms except conductive hearing loss.

Though antibiotics have proven to be effective for children with acute OM where biofilms have not yet formed, those with chronic disease typically benefit little from the drugs and more so from myringotomy, a surgical procedure in which small tubes are placed in the eardrum to continuously drain infectious fluid (called effusion).

Working with Dr. Kerschner, Drs. Ehrlich and Post obtained middle ear muscosa – or membrane tissue – biopsies from children undergoing myringotomy for OM with effusion (OME) and ROM. The team gathered uninfected mucosa biopsies from children and adults undergoing cochlear implantation as a control.

Using advanced confocal laser scanning microscopy, three dimensional images were obtained of the biopsies and evaluated for biofilm morphology using generic stains and species-specific probes for Haemophilus influenzae, Streptococcus pneumoniae and Moraxella catarrhalis by Luanne Hall Stoodley, Ph.D. and her ASRI colleagues. Effusions, when present, were also evaluated for evidence of pathogen specific nucleic acid sequences (indicating presence of live bacteria).

The study found mucosal biofilms in the middle ears of 46/50 children (92%) with OME and ROM. Biofilms were not observed in eight control middle ear mucosa specimens obtained from cochlear implant patients.

“Our findings demonstrate what we have suspected for years, that children with chronic otitis media have biofilms in their middle ears. Healthy children do not. The idea of treating recurrent disease with antibiotics therefore is not supported by the scientific evidence,” Dr. Post said. “Chronic middle ear infection is not the result of a sterile inflammatory process, but an indolent bacterial disease. Understanding that, we can now begin to explore more effective treatments for it.”

Dr. Post said future therapies may be medical, technological or biological in nature, including the use of probiotics – an approach in which children are deliberately populated – but not infected – with good bacteria that prevent the formation of biofilms. In an ongoing study at the University of Florida, researchers are inoculating children against cavities using a bacteria that sets up house in their teeth where plaque biofilms usually grow.

“The idea with chronic middle ear infections would be to engineer a bacteria that could occupy the nasopharynx but not cause recurring infection,” Dr. Post said.

“Until something new comes along, however, placement of ear tubes to provide children with symptomatic relief will still be necessary and recommended. Antibiotics should also continue to be prescribed for acute otitis media to help prevent potentially serious complications, such as mastoiditis and meningitis,” Dr. Kerschner said.

Research To Speed Up Cure For Ear Infections

Fast tracking the healing process for common ear infections will be the focus of ground-breaking research by WA’s Lions Ear and Hearing Institute (LEHI).

The research will aim to understand why some eardrums heal by themselves (and why some do not heal at all) by identifying which genes are responsible for the wound-healing process of an infected human ear drum.

According to the World Health Organisation, almost half of the world’s population suffers from ‘chronic otitis media’ – more commonly known as an ear infection – which causes hearing loss and can lead to more serious disorders such as meningitis.

Ear infections can occur when ear drums burst as a result of a loud explosion, trauma or most commonly by infection spread by a common cold or sore throat.

LEHI’s Senior Research Scientist Dr Reza Ghassemifar, said he was looking forward to starting the three-year research project after securing a $238,600 grant from the Garnett Passe and Rodney William Memorial Foundation.

“With this funding we can start our studies to understand how wounds in ear drums heal themselves by examining the cells and molecules in the replacement tissue,” Dr Ghassemifar said.

“Through DNA or gene profiling of animal models we hope to learn which molecules are active as the ear drum heals and we will then target those to speed up the healing process.”

Dr Ghassemifar said the clinical research into the wound healing process was a major milestone towards LEHI’s major tissue engineering project of growing a replacement human ear drum.

“If we can understand how an ear drum heals itself we can help clinicians identify new techniques to speed up the healing process for sufferers of ear infections.

“Ear infections are a major worldwide health problem and it is common for an average person to take up to 10 years before they receive medical treatment.

“We tend to ignore ear infections thinking they will go away or we might have a reluctance to visit the doctor – but in third-world countries the problem is common due to the lack of available treatment,” he said.

Dr Ghassemifar said the results of other gene targeting research have indicated that gene therapy (to target wound healing genes) could prevent wound scarring and be potentially applied to clinical scar treatments.

Professor Marcus Atlas, Director of LEHI, said that Dr Ghassemifar’s work in LEHI’s Tissue Engineering Laboratory is potentially ground breaking.

“Chronic otitis media is a major problem throughout the world and particularly affects the indigenous Australian population. These studies have the potential to help greatly”, Professor Atlas said.

Most Ear Infections Host Both Bacteria And Viruses

Ear infections are among the most common diseases seen in pediatric practice. They have generally been considered bacterial diseases and are therefore usually treated with antibiotics. New research, published in the December 15 issue of Clinical Infectious Diseases and currently available online, provides evidence that viruses are found in a great many ear infection cases and may complicate treatment.

The researchers used a variety of laboratory techniques to identify the pathogen that caused ear infections, known clinically as acute otitis media (AOM), in 79 young children. They found bacteria in 92 percent of the cases, viruses in 70 percent, and both bacteria and viruses in 66 percent.

According to Aino Ruohola, MD, PhD, from the Turku University Hospital in Finland and lead author of the study, “the major finding of the study is that acute otitis media is a coinfection of bacteria and viruses in the great majority of children. This is actually logical since acute otitis media is virtually always connected to viral respiratory infection.”

Antibiotics, which are effective against the bacteria that cause AOM, have no effect on the viruses found in AOM infections. Therefore, the standard treatment for AOM–antibiotics–can be, at best, partially effective in the majority of cases. “Based on this and previous research,” said Dr. Ruohola, “it is possible that viruses cause a considerable proportion of clinical treatment failures. Thus, in these cases a new antibiotic is not necessarily the best choice although bacteria resistant to common antibiotics are wide-spread.”

The good news is that many cases of AOM recover spontaneously without antibiotic treatment, a fact that has led the American Academy of Pediatrics and the American Academy of Family Physicians to recommend withholding antibiotic treatment in mild AOM cases.

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In an accompanying editorial, Tasnee Chonmaitree, MD, from the University of Texas Medical Branch, notes that studies of AOM have shown that viruses may impair antibiotic efficacy by several mechanisms. “Further studies,” she writes, “are required to determine the effect of combined bacterial and viral infections of the respiratory tract in adults and children.” She says that if this joint bacterial/viral infection concept also applies to respiratory diseases such as sinusitis and pneumonia, then the expectation of antibiotic efficacy in these diseases needs to be adjusted.

Earache should not be treated with antibiotics

Soon some expects will be telling doctors not to treat ear infections with antibiotics.

This goes against years of medical practice. 50% of antibiotic prescriptions for pre-school kids are for ear infections.

Officials say that reducing the number of antibiotics in these cases will stop the increase in antibiotic-resistant germs.

Dr. Richard Besser, of the meningitis and special pathogens branch of the Centers for Disease Control and Prevention said ‘It will mark a dramatic change in appropriate antibiotic use.’

The American Academy of Pediatrics and the American Academy of Family Physicians guidelines have to be approved before they are forwarded on to doctors.

The experts are saying that doctors should not use antibiotics if the child’s ear infection is not serious. Most kids recover in 2-7 days anyway, 80% of them.

A member of the committee examining the guidelines, Dr. Richard Rosenfeld said ‘We are making a societal trade-off — at the individual level, some kids may have a little bit longer course of their infection, but for society as a whole, we will be better served if we don’t give them. We should save the power of antibiotics for people with real significant illnesses where 80 percent don’t get better in a day or two and can actually die.”

The guidelines will say that antibiotics should only be used for acute otitis media (serious middle ear infection). The child must have a high temperature (102.6 degrees Fahrenheit) and/or severe pain in the ear.

The guidelines will say that milder cases can be treated by simply observing the child.

In the USA 10 million prescriptions are written each year for ear infections in kids up to 18 years of age.

Breast-Feeding Overcomes A Genetic Tendency Toward Ear Infections

Breast-feeding protects children otherwise made susceptible to ear infections by abnormalities in specific human genes, researchers at the University of Texas Medical Branch at Galveston have discovered.

About 19 percent of children are prone to chronic and recurrent ear infections (known to physicians as “otitis media”). These infections can interfere with language development and lead to learning difficulties. Scientists have long known that genetics plays a role in this vulnerability, but very few investigations have been done to pinpoint the specific genes involved. Their complex relationship with specific infectious agents and environmental factors such as exposure to cigarette smoke and breast-feeding also has remained largely a mystery.

The UTMB study, published in the December issue of the journal Pediatrics, examined genetic samples taken from 505 children in Texas and Kentucky, about 60 percent of whom were classified as “otitis media susceptible” because they had suffered an ear infection before the age of 6 months; had undergone three or more episodes of acute otitis media within a six-month period; had four or more episodes within a 12-month period; or had six or more episodes by age 6. Children who had required drainage tubes to assuage recurrent or persistent ear infections were also placed in the “susceptible” category.

“We know that the tendency to get this infection runs in families, and so we decided to look for small variations – what we call ’single-nucleotide polymorphisms,’ or SNPs – in three important genes that produce inflammatory signaling molecules for the immune system,” said lead author Janak A. Patel, a professor in the infectious disease division of UTMB’s Department of Pediatrics. “Two of them stood out on their own as signals of increased risk.”

The two identified genes generate the immune proteins known as tumor necrosis factor alpha (TNF-alpha) and interleukin 6 (IL-6). SNPs in each individual gene were enough, the researchers found, to create increased risk for childhood ear infections, and simultaneous SNPs in both genes created even more risk. The researchers believe that the particular variations detected cause greater production of inflammatory signaling molecules and reduce immune system effectiveness. But the UTMB scientists found that the effect could be counteracted with a practice long known to increase immune resistance: breast-feeding.

“This is a major finding, that breast-feeding neutralized the effect even in kids who had all the genetic polymorphisms,” Patel said. “Not only that, they were protected from recurrent infections even later in childhood, long after they stopped breast-feeding.”

By contrast, the group found that another environmental factor – exposure to cigarette smoke – increased vulnerability to otitis media in children with the TNF-alpha gene variation. Cigarette smoke exposure alone, however, was not enough to increase risk for ear infections.

Pneumococcal vaccine reduces ear infections

The pneumococcal conjugate vaccine, which has been routinely given to young children since 2000, reduces the incidence of middle ear infection and pneumonia, a new study shows. “This highlights that the vaccine significantly decreases illnesses in children and reinforces its importance in our public health efforts,” said Dr. Kathy Poehling, assistant professor of Pediatrics at Vanderbilt University Medical Center and Vanderbilt Children’s Hospital in Nashville.

The study appears in the September issue of the journal “Pediatrics.”

The pneumococcal conjugate vaccine is well known to control bacterial meningitis and bacteremia — a bacterial infection in the blood system — but doctors needed good evidence that it helped control other illnesses.

Ear infections (otitis media) and pneumonia are common infections in children; there are more than seven million cases of ear infection and more than one half million cases of pneumonia each year.

Poehling and colleagues studied data from Tennessee’s Medicaid records and from three commercial insurance companies in upstate New York. They found that after routine vaccination with the pneumococcal conjugate vaccine began children in Tennessee younger than 2 years old had 7 percent fewer cases of otitis media in Tennessee; 20 percent of these children New York got ear infections.

Likewise, there were 17 percent fewer cases of pneumonia in Tennessee and 30 percent fewer cases in New York. These translate to about 10 fewer doctor visits, per 100 children, in Tennessee for ear infections and 40 fewer in New York; there were two fewer visits, per 100, for pneumonia in Tennessee and four fewer in New York.

“The cost control implications — reducing emergency department and outpatient visits — are also very important,” Poehling said.

The study provides “the first data that demonstrate a decline in all pneumococcal-related diseases, not just invasive disease, in children aged younger than 2 years since the introduction of pneumococcal conjugate vaccine in the United States,” Poehling and colleagues wrote in the journal.

Long term outcomes for children who undergo ear tube placement surgery

Infants and young children who undergo surgery to insert ventilation tubes in their ears as a treatment for ear infections have hearing levels comparable to normal children 14 years later, although children with more serious disease may require repeat procedures or other ear surgery, according to two studies in the April issue of Archives of Otolaryngology-Head & Neck Surgery, one of the JAMA/Archives journals.

Ear infections (otitis media or OM) and ear infections with accumulated fluid (otitis media with effusion or OME) bring young children into physicians’ offices more than any other childhood disease, according to background information in the article. Recurrent acute otitis media (RAOM) and otitis media with effusion are the main reason for the insertion of ventilation tubes (VT) in the ear. Minor surgery to drain the ear and insert tubes in the ear is the most common surgical procedure among young children in the United States. Instant improvement of hearing is one of the beneficial effects of the surgery and, the authors suggest, may be associated with long-term reduction in risk of subsequent language, educational and developmental impairments.

Hannu Valtonen, M.D., Ph.D.,of Kuopio University Hospital, Kuopio, Finland, and colleagues report on the results of follow-up checkups 14 years following surgery for 237 children who had tubes inserted to treat ear infections at the age of five to16 months. The children had also participated in an earlier follow-up visit five years following the surgery. In addition to assessing their hearing levels, children were assessed on whether the ear had healed, for a history of repeat procedures, for abnormal outcomes and on whether they required more extensive ear surgery.

The hearing level of healed ears was comparable to that of age-matched normal ears. “Ear surgery, which sometimes becomes necessary, is not hazardous for hearing, as such, but in the case of chronic middle ear infection may be insufficient to retain normal hearing or restore it to normal levels,” the authors write.

At the 14 years’ follow-up 177 (74.7 percent) of the children’s ears had healed, up from 156 (65.8 percent) at five years following surgery. The number of abnormal outcomes decreased from 81 (34.2 percent) at five years to 60 (25.3 percent) at 14 years. Abnormal outcomes were more common when the child had an ear infection with accumulated fluid, or had required three or more tube insertions. Repeated tube insertion and other ear surgery was also more common in those with the more serious condition.

“Based on our results, we conclude that tympanostomy tube insertion early in life, and repeated if necessary, for OME or RAOM is a safe and useful treatment method,” the authors conclude. “Parents should be informed of the long follow-up, of the possible need for repeated VT insertion, and of potential sequelae that sometimes necessitate surgical intervention. Patients healed after five years do not need further follow-up.”

Worldwide Fight Against Respiratory Infections

The new Capricornia Centre for Mucosal Immunology has been established under the leadership of Professor Jennelle Kyd, whose research on immunity and vaccines is recognized internationally.

Professor Kyd is collaborating with researchers in Australia, Europe and the USA and is working with major pharmaceutical companies on the research and development of patents to the clinical trials stage for a range of new therapies.

“We currently treat respiratory infections with antibiotics but we need to find better preventative therapies otherwise we’ll continue increase the emergence of bacteria that are drug resistant. Vaccines offer the best strategy for long term prevention of infections,” she said.

One of the major focus areas of the Centre is middle ear infection – the most common childhood illness for which medical advice is sought and antibiotics administered.

Up to 80% of Australian children have at least one episode of middle ear infection in their first 3 years and about one third of these will suffer recurrent or chronic middle ear infections.

Professor Kyd said while the new paediatric pneumococcal vaccine targets some of the problem bacteria, but there is a gap in vaccine coverage, meaning that children still become infected by the other bacteria that cause the same type of infection. Many children suffer pain, require repeated courses of antibiotics, and some go on to need tubes inserted to control the chronic infections. The consequence of persistent middle ear infections is hearing impairment that can result in delays in speech and language development.

The Centre is seeking to improve vaccine technologies and non-injection type delivery systems for protection against a range of respiratory bacterial infections.

As part of the strategy, the Centre is examining the interactions between the various bacteria involved in the respiratory systems to see how they compete and interact with each other, thus influencing the likelihood of an infection.

“We are also trying to identify why Indigenous kids are even more prone to middle ear infections. A controlled study has shown that socio-economic reasons do not fully explain this propensity, and many of our indigenous children succumb to middle ear infections at an earlier age and go on to suffer serious recurrent or chronic middle ear infections.”

The Centre not only undertakes basic research but is also collaborating with others on vaccine R&D, clinical trials, health issues and vaccine systems around the world.

Children Prone to Ear Infections Have High Rates of Disease Producing Bacteria

Children who are prone to frequent ear infections may have a high number of potentially infectious bacteria and a relatively low number of protective bacteria in their noses, according to a study in the June issue of Archives of Otolaryngology-Head & Neck Surgery, one of the JAMA/Archives journals.

Smoking is associated with an increased risk of respiratory tract infections in adults and also with oral colonization by some potentially pathogenic species of bacteria, according to background information in the article. In children, exposure to cigarette smoke is a risk factor for respiratory tract infections, including otitis media (ear infections). This study compared the frequency of potential pathogens (infectious bacteria) and of “interfering” bacteria (potentially protective bacteria) in otitis media-prone (OMP) children and their smoking or non-smoking parents.

Itzhak Brook, M.D., M.Sc. and Alan E. Gober, M.D., of Georgetown University School of Medicine, Washington, D.C., compared potential pathogens and bacteria with interfering capabilities against those organisms cultured from samples taken from the back of the noses of two groups, 20 ear infection-prone children and their non-smoking parents and 20 ear infection-prone children and their smoking parents.

The researchers found 14 potential pathogens in the smoking parents and 17 in their children, compared with three potential pathogens in non-smoking parents and 16 in their children. Bacterial interference against potential pathogens were noted in 58 instances in smoking parents and in 55 instances in their children compared to 129 instances in non-smoking parents and 55 instances in their children.

“A high recovery rate of potential pathogens and a low number of interfering organisms were observed in OMP children,” the authors write. “This was not related to their parents’ smoking habits. The posterior nasopharynx flora of smoking parents contained more pathogens similar to the ones recovered from OMP children and fewer interfering organisms than non-smoking parents.”

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Arch Otolaryngol Head Neck Surg. 2005; 131:509-512.