Can the Influenza Vaccine Prevent Acute Otitis Media?

Acute otitis media (AOM) is a common pediatric infection among children in high-income countries, with an estimated 80% of children experiencing at least 1 episode by the time they reach 3 years of age.¹ Otitis media broadly refers to any infection or inflammation of the middle ear, which can present as fluid behind an intact tympanic membrane with or without signs of acute infection (if such signs are absent, it is referred to as otitis media with effusion) or as a perforated tympanic membrane with purulent discharge (chronic suppurative otitis media) lasting for more than 6 weeks.²

Risk factors for AOM include a family history of otitis media, bottle feeding, attending day care, environmental allergies, and low socioeconomic status. Although it has been found that more than 87% of AOM cases are caused by bacterial pathogens, they are often triggered by a viral infection.^3,4 In a cohort study of children in day care, viral pathogens were associated with an elevated risk for AOM over the 14-year study period.⁵ Other research on children with AOM detected respiratory viruses in 42% of fluid specimens from the middle ear.⁶

AOM “is a condition for which there is considerable overuse of antibiotics,” said Ebbing Lautenbach, MD, MPH, MSCE, chief of the infectious diseases division and associate professor in the Perelman School of Medicine at the University of Pennsylvania. According to data from the Centers for Disease Control and Prevention, AOM is reported to be the top reason for antibiotic prescription for US children.⁷ “Given the critical role of antibiotic use in driving the continued emergence of antibiotic resistance, identifying strategies to reduce antibiotic use in children is important,” Dr Lautenbach told Infectious Disease Advisor.

To that end, a new review published in the Cochrane Database of Systematic Reviews examined evidence pertaining to the effectiveness of influenza vaccines in preventing AOM in infants and children.⁸ Studies included 11 randomized controlled trials that compared influenza vaccine with no treatment or placebo in participants under the age of 6 years, with or without a history of AOM. The trials involved a total of 17,123 children ranging in age from 6 months to 6 years. Ten of the trials disclosed the receipt of funding from vaccine manufacturers.

The overall results reveal that influenza vaccination was associated with a 4% reduction in AOM and an 11% reduction in antibiotic use for AOM. Specific observations are summarized below.

• A small decrease in at least 1 episode of AOM over at least 6 months of follow-up (4 trials, n=3134; relative risk [RR] 0.84; 95% CI, 0.69-1.02; risk difference [RD] -0.04; 95% CI, -0.08 to -0.00; number needed to treat for an additional beneficial outcome, 25; 95% CI, 12.5-100; evidence judged to be low quality)
• No differences in subgroup analyses by vaccine type (live or inactivated and whole, split-virus, or subunit-type vaccines) and number of courses
• A reduction in antibiotic use among vaccinated children (2 trials, n=1223; RR 0.70; 95% CI, 0.59-0.83; RD -0.11; 95% CI, -0.16 to -0.06; moderate-quality evidence)
• Although no major adverse events were reported, influenza vaccine led to a significant increase in fever (7 trials, n=10,615; RR 1.15; 95% CI, 1.06-1.24; RD 0.02; 95% CI, 0.00-0.04; low-quality evidence), rhinorrhea (6 trials, n=10,563; RR 1.17; 95% CI, 1.07-1.29; RD 0.09; 95%CI, 0.01-0.16; low-quality evidence)

“Influenza vaccination is already recommended for children >6 months of age. This study demonstrates that vaccination may confer modest reductions in AOM and AOM-targeted antibiotic use,” said Dr Lauterbach. Promotion of the influenza vaccine as a strategy to reduce AOM is likely unjustified, although the review authors stated that “many factors… influence parents’ decisions whether or not to vaccinate their child,” and they may want to consider these results in making such decisions.

However, as data on serious adverse effects of the influenza vaccine were scarce across the studies reviewed, more evidence is needed to further elucidate its potential value in reducing antibiotic usage. “The benefits may not justify the use of influenza vaccine without taking into account the vaccine efficacy in reducing influenza and safety data,” wrote the authors.

Dr Lautenbach noted that there have been considerable efforts in recent years to reduce the use of antibiotics in children seen in outpatient settings, many of which focus on greater provider education and feedback. “Future research should examine how strategies to improve vaccination rates can be incorporated into ongoing antibiotic stewardship efforts to further decrease unnecessary outpatient antibiotic use.”

Although the current review found that influenza vaccine was associated with a small reduction in AOM and antibiotic use in children, it is not likely to be justified as a general strategy to prevent AOM. Further study on the topic is needed. 

References

1. Vergison A, Dagan R, Arguedas A, et al. Otitis media and its consequences: beyond the earache. Lancet Infect Dis. 2010;10:195-203.
2. Leach AJ, Morris PS. Antibiotics for the prevention of acute and chronic suppurative otitis media in children. Cochrane Database Syst Rev. 2006;(4):CD004401.
3. Block SL, Harrison CJ, Hedrick JA, et al. Penicillin-resistant Streptococcus pneumoniae in acute otitis media: risk factors, susceptibility patterns and antimicrobial management. Pediatr Infect Dis J. 1995;14:751-759.
4. Heikkinen T, Chonmaitree T. Importance of respiratory viruses in acute otitis media. Clin Microbiol Rev. 2003;16:230-241.
5. Henderson FW, Collier AM, Sanyal MA, et al. A longitudinal study of respiratory viruses and bacteria in the etiology of acute otitis media with effusion. N Engl J Med. 1982;306:1377-1383.
6. Monobe H, Ishibashi T, Nomura Y, Shinogami M, Yano J. Role of respiratory viruses in children with acute otitis media. Int J Pediatr Otorhinolaryngol. 2003;67:801-806.
7. Centers for Disease Control and Prevention. Antibiotic Prescribing and Use in Doctor’s Offices. Updated September 25, 2017. Accessed December 1, 2017.
8. Norhayati MN, Ho JJ, Azman MY. Influenza vaccines for preventing acute otitis media in infants and children. Cochrane Database Syst Rev. 2017;10:CD010089.