Influence of pneumococcal conjugate vaccines on acute otitis media in Japan

A population-based study on the burden of hospitalized pediatric pneumococcal disease in Taiwan before and after the introduction of 13-valent pneumococcal conjugate vaccine into the childhood immunization program in 2015

BACKGROUND

To estimate the burden of invasive pneumococcal disease, non-bacteremic pneumococcal pneumonia, and acute otitis media before and after inclusion of the 13-valent pneumococcal vaccine (PCV13) into Taiwan's Childhood Immunization Program in 2015.

METHODS

Episodes of eligible children aged < 18 years hospitalized with invasive pneumococcal disease, non-bacteremic pneumococcal pneumonia, or acute otitis media between 1 January 2011 and 31 December 2019 were identified from the National Health Insurance Research Database. Annual hospitalized incidence rate, case fatality rate, and healthcare resource utilization and costs were estimated. Incidence time trends were assessed with interrupted time series analyses.

RESULTS

1,284 invasive pneumococcal disease episodes, 25,074 non-bacteremic pneumococcal pneumonia episodes, and 23,139 acute otitis media episodes were identified. The overall annual incidence rates of invasive pneumococcal disease, non-bacteremic pneumococcal pneumonia, and acute otitis media were 3.31, 64.61, and 59.62 episodes per 100,000 person-years, respectively. Interrupted time series analyses results showed a significantly lower baseline incidence rate (incidence rate ratio [IRR]:0.58, p-value = 0.001) for invasive pneumococcal disease, and significantly higher baseline incidence rate (IRR:1.17, p-value < 0.001) for non-bacteremic pneumococcal pneumonia in the post-PCV13 period. Baseline incidence rates between the two periods were comparable for acute otitis media. A significant increase in trend of incidence rate was observed for all three diseases. Case fatality rate was 1.79%, 0.09%, and 0.00% for invasive pneumococcal disease, non-bacteremic pneumococcal pneumonia, and acute otitis media, respectively. Median length of hospitalization per inpatient visit was comparable between the two periods for invasive pneumococcal disease and non-bacteremic pneumococcal pneumonia, but significantly shorter in the post-PCV13 period for acute otitis media. In the post-PCV13 period, average total costs per episode was lower for invasive pneumococcal disease and non-bacteremic pneumococcal pneumonia, but higher for acute otitis media.

CONCLUSIONS

Residual clinical and economic burden of pneumococcal diseases remained substantial after PCV13 inclusion into Taiwan's Childhood Immunization Program. To further reduce the disease burden among children, additional research to investigate the cause of increasing trends of hospitalized invasive pneumococcal disease, non-bacteremic pneumococcal pneumonia and acute otitis media in the post-PCV13 era will be required.

Pediatric otitis media in Japan: A nationwide longitudinal study of the pre- and post-pneumococcal conjugate vaccine eras born in 2001 and 2010

BACKGROUND

Otitis media (OM) is a prevalent respiratory disease in children and poses significant public health challenges due to its impact on child health and economic burdens. However, there have no nationwide epidemiological studies conducted in Japan. This study investigates the epidemiological trends of OM in Japan, taking into account the impact of the 7-valent pneumococcal conjugate vaccine (PCV7) introduction.

METHOD

This study was retrospective cohort study using secondary data on the nationwide longitudinal birth cohort. This survey followed two cohorts born in 2001 (pre-PCV era) and 2010 (post-PCV era) until the age of 9. Every year, parents were surveyed about their children's health status, including occurrences of OM. The annual period prevalence and cumulative incidence of OM were assessed in this study, and the two cohorts were compared using a modified Poisson regression model adjusted environmental factors with the 2001 cohort as reference.

RESULT

The study included 47,015 children from the 2001 cohort and 38,554 from the 2010 cohort. Peak annual period prevalence of OM varied by era. Cumulative incidence was 13.8 % for the 2001 cohort and 18.5 % for the 2010 cohort by 1.5 years of age and 28.9 % and 33.3 %, respectively, by 3.5 years of age. In particular, from the fourth survey onward, covering ages 2.5-3.5 years, a shift was observed from an increased risk to a decreased risk of OM.

CONCLUSION

This nationwide longitudinal study emphasizes variations in OM epidemiology across Japan over time, with changes potentially influenced by the introduction of PCV7. In this study, due to the absence of individual PCV7 vaccination data, the effect of PCV7 was estimated based on the vaccination rate at the population level. The results suggest a notable decrease in the incidence of OM in later years, aligning with the increased uptake of PCV7.

Effectiveness of Pneumococcal Vaccines on Otitis Media in Children: A Systematic Review

OBJECTIVES

We aimed to determine the effectiveness of pneumococcal vaccines on otitis media (OM) and acute otitis media (AOM) in children.

METHODS

We conducted a systematic search in databases PubMed (MEDLINE), Embase, Lilacs, and Web of Science. We included observational studies that evaluated any pneumococcal vaccine - including 7, 10, and 13-valent pneumococcal conjugate vaccines (PCV7, PCV10, and PCV13) and 23-valent polysaccharide vaccines (PPSV23) as the intervention, in children aged less than five years.

RESULTS

Out of the 2112 screened studies, 48 observational studies complied with the eligibility criteria and therefore were included in this review. Of the included studies, 30 (63%) were before-after, eleven (23%) cohort, six (13%) time series, and one (2%) case-control study designs. Vaccine effectiveness (VE) in preventing OM or AOM varied by vaccine type. In children under 24 months VE ranged from 8% and 42.7% (PCV7), 5.6% to 84% (PCV10) and 2.2% to 68% (PCV13). In children aged less than 60 months, VE ranged between 13.2% and 39% for PCV7, 11% to 39% for PCV10 (only children under 48 months), and 39% to 41% (PCV13).

CONCLUSIONS

Our results demonstrate significant effect of pneumococcal vaccination in decreasing OM or AOM in children under five years old in several countries supporting the public health value of introducing PCVs in national immunization programs.

Pneumococcal conjugate vaccines reduce myringotomy with tympanostomy tube insertion in young children in Japan

OBJECTIVE

Pneumococcal conjugate vaccines (PCVs) have been reported to reduce the incidence of myringotomy with tympanostomy tube insertion (MTTI) in children. However, little information is available focusing specific ages. We examined the prophylactic efficacy of PCVs on the onset of complex otitis media (ComOM) that requires MTTI.

METHOD

From 2011, the public support for PCV7 started with the usual four-dose schedule and an emergency schedule for 2- to 4-year-old children in Japan. PCV7 was replaced with PCV13 in 2013. We reviewed the nationwide database obtained from the JMDC Claims Database (https://www.jmdc.co.jp/en/) to examine the MTTI incidence during the era before and after PCV introduction (from 2008 to 2010 and from 2011 to 2017, respectively). Subjects were analyzed by stratified age groups (from 0 to 8 years old) and in subdivided groups of 6 months (from 0 to 35 months old). We compared the MTTI incidence between the groups for each age as well as between those for each calendar year.

RESULTS

A significant reduction in the MTTI incidence was detected in the 1-year-old children of the PCV era compared to those of the pre-PCV era. The reduction rates were more prominent in the 12-17 months group as compared to the 18-23 months group (PCV7 p = .005 and PCV13 p = .011, PCV7 p = .014 and PCV13 p = .153, respectively). The significant difference in the 1-year-old children continued in six of seven calendar years from 2011 to 2017, whereas no significant reduction was detected in children >3 years old.

CONCLUSIONS

The introduction of both PCV7 and PCV13 reduced MTTI incidences in children around 1 year old, and the effects were more prominent during the early half-periods. Our results support etiological evidence that pneumococcal infection in children aged 1 year and younger might play roles in the pathogenesis of ComOM that requires MTTI.

Improvement in the appropriate antimicrobial usage for treating pediatric acute otitis media in Japan: A descriptive study using nation-wide electronic medical record data

OBJECTIVES

We investigated changes in prescriptions for antimicrobial agents to treat children with acute otitis media (AOM).

METHODS

A descriptive study using an electronic medical record database. Of 199,896 patients enrolled between 2001 and 2019, a total of 10,797 were aged <16 years and had AOM as their first and primary disease (overall pediatric AOM cohort). In addition, 4786 patients with AOM without other comorbidities (pediatric AOM cohort) were included.

RESULTS

In the overall pediatric AOM cohort, the age distribution ranged from 11% to 23% for those younger than 2 years and from 66% to 77% for those younger than 6 years, with no change over time. In the pediatric AOM cohort, the antimicrobial prescription rate was 91% in 2001 but declined to 40% by 2019. Antimicrobial use increased from 0% to 75% for penicillins, whereas use of cephalosporins decreased from 84% to 10%. The prescription rate for acetaminophen alone increased from 33% to 58%. There were no differences in the incidence of adverse reactions among the prescribed antimicrobials.

CONCLUSIONS

Due to education efforts and promotion of the proper use of antimicrobials through means such as the Clinical practice guidelines for the diagnosis and management of acute otitis media in children (2006) and the Manual of Antimicrobial Stewardship (2016), a change in the use of antimicrobials occurred, leading to a trend to more proper use of these agents.

Clinical practice guidelines for the diagnosis and management of acute otitis media in children-2018 update

OBJECTIVE

"Clinical Practice Guidelines for the Diagnosis and Management of Acute Otitis Media in Children-2018 update (2018 Guidelines)" aim to provide appropriate recommendations about the diagnosis and management of children with acute otitis media (AOM), including recurrent acute otitis media (recurrent AOM), in children under 15 years of age. These evidence-based recommendations were created with the consensus of the subcommittee members, taking into consideration unique characteristics of bacteriology and antimicrobial susceptibilities of AOM pathogens in Japan, as well as global advances in vaccines.

METHODS

The subcommittee re-evaluated key clinical issues based on SCOPE (a master plan of the guidelines) and created clinical questions (CQ) about the diagnosis and management of AOM patients. A literature search of the publications from 2013 to 2016 were added to the Guidelines 2013, not only to assess the evidence on the effectiveness of vaccines, but also to provide up to date information of the bacteriology and antimicrobial susceptibilities of AOM causative pathogens in Japan.

RESULTS

We have proposed guidelines for disease severity-based management of AOM patients, after classifying AOM severity into mild, moderate, and severe, based on age, clinical manifestations, and otoscopic findings.

CONCLUSIONS

Precise otoscopic findings are essential for judging AOM severity, which can lead to appropriate management of AOM patients.

Updated Guidelines for the Management of Acute Otitis Media in Children by the Italian Society of Pediatrics: Prevention

BACKGROUND

In recent years, new information has been acquired regarding the diagnosis, treatment and prevention of acute otitis media (AOM). The Italian Pediatric Society, therefore, decided to issue an update to the Italian Pediatric Society guidelines published in 2010.

METHODS

The search was conducted on Pubmed, and only those studies regarding the pediatric age alone, in English or Italian, published between January 1, 2010 and December 31, 2018, were included. Each study included in the review was assessed using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) methodology. The quality of the systematic reviews was evaluated using the A MeaSurement Tool to Assess systematic Reviews (AMSTAR) 2 appraisal tool. The guidelines were formulated using the GRADE methodology by a multidisciplinary panel of experts.

RESULTS

The importance of eliminating risk factors (passive smoking, environmental pollution, use of pacifier, obesity, limitation of day-care center attendance) and the promotion of breastfeeding and hygiene practices (nasal lavages) was confirmed. The importance of pneumococcal vaccination in the prevention of AOM was reiterated with regard to the prevention of both the first episode of AOM and recurrences. Grommets can be inserted in selected cases of recurrent AOM that did not respond to all other prevention strategies. Antibiotic prophylaxis is not recommended for the prevention of recurrent AOM, except in certain carefully selected cases. The use of complementary therapies, probiotics, xylitol and vitamin D is not recommended.

CONCLUSIONS

The prevention of episodes of AOM requires the elimination of risk factors and pneumococcal and influenza vaccination. The use of other products such as probiotics and vitamin D is not supported by adequate evidence.

Impact of the 13-valent pneumococcal conjugate vaccine on the incidences of acute otitis media, recurrent otitis media and tympanostomy tube insertion in children after its implementation into the national immunization program in Turkey

The aim of this study was to investigate changes in the incidences of acute otitis media (AOM), recurrent AOM (rAOM) and tympanostomy tube (TT) insertion in children following the introduction of 13-valent pneumococcal conjugate vaccine (PCV13) into the national immunization program (NIP) of Turkey in April 2011. National coverage for the PCV7 was 97% in 2009, 93% in 2010, 96% in 2011 and for the PVC13 was 97% in 2012, 97% in 2013, 96% in 2014, 97% in 2015, 98% in 2016, and 96% in 2017 for Turkish children younger than 12 months of age. A total of 499932 pediatric visits were recorded, and AOM was diagnosed in 23005 (4.6%) children. The incidence of AOM in children ≤5 years of age decreased from 10700/100000 (2011) to 4712/100000 (2017), with a significant decreasing trend (p < .001, r = -0.965). When the mean annual incidences of AOM between the transition period of PCV13 (years 2011/2012) were compared with those of a post-PCV13 period (years 2016/2017) for children ≤5 years of age, the incidence of AOM was found to be decreased by 54% (p = 0.013). The mean incidence of TT insertion was found to be decreased by 65% (p = 0.003) between the transition period of PCV13 and a post-PCV13 period for children ≤5 years of age. On the other hand, rAOM incidence was found to be increased in whole pediatric age groups. Our study showed a significant decrease in the incidences of AOM and TT insertion in children ≤5 years old after implementation of PCV13 in the NIP in Turkey.