The Infectious Aetiology of Otitis
Media in Young Children
Nikki Mills
Emma Best
Tony Walls
Paed ENT Consultant, Starship
Paed Inf Dis Consultant, Starship
Paed Inf Dis Consultant, Canterbury
Starship
CHILDREN’S HEALTH
Disclosure Statement
This is investigator led research with funding from:
Glaxo-Smith Kline (GSK)
&
an Auckland District Health Board
Research Grant
The Researchers have not received
any personal funding or salary from GSK
Otitis Media In New Zealand
Gold Coast
New Zealand
2,220kms
OMIVI Study
Otitis Media Infectious aetiology & Vaccination Impact
- Prospective descriptive study < 3 y olds
- Nasopharyngeal flora
- Bacteria present in middle ear fluid
- Impact of pneumococcal vaccination change:
Phase 1 – 2011: Cohort PCV7 (2008)
Phase 2 – 2014: Cohort PHiD-CV (Dec 2011)
- Interest in the impact of PHiD-CV on H.inf
OMIVI Study
Phase 1: 2011: 462 participants < 3 y olds
Phase 2: 2014: 473 participants
Phase 1 : 325
Phase 2 : 319
Phase 1 : 137
Phase 2 : 154
Grommet patients
Comparison group
RAOM & OME
No sig history ear disease
Questionnaire
&
Nasopharyngeal Swab
Middle ear samples
PCR
Culture
Pneumococcal
Serotyping
OMIVI Phase 1 & 2 Papers
2014
2016
OMIVI Study
Phase 1: 462 participants
Phase 2: 473 participants
Phase 1 : 325
Phase 2 : 319
Phase
319
< 3 y olds
Phase 1 : 137
Phase 2 : 154
Grommet patients
Comparison group
RAOM & OME
No sig history ear disease
Questionnaire
&
Nasopharyngeal
NasopharyngealSwab
Swab
Middle
Middleear
earsamples
samples
PCR
Culture
PCR for
Respiratory
Viruses
Pneumococcal
Serotyping
Otitis Media Infectious Aetiology Study
old: RAOM
<<33yyold
RAOM&/or
&/orOME
OME
Grommet
Grommetinsertion
insertion
N = 319
PCV10
vaccinated
cohort
Bilateral Dry Ears
N = 102
Fluidpresent
presentone
oneor
orboth
bothears
ears
Fluid
217
nN==217
Questionnaire
Questionnaire
&
Nasopharyngeal
SwabSwab
N = 217
Nasopharyngeal
&
Middle
ear samples
n = 376
Middle
ear samples
Viral
PCR
Bacterial
PCR
Bacterial
Culture
Pneumococcal
Serotyping
3 Study Centres
Recruitment:
7 months: 1 May – 30 Nov 2014 (winter)
77% of all <3 year olds receiving grommets
2 in Auckland
1 in Christchurch
Questionnaire
Otitis Media Risk Factors
•
•
•
•
•
•
•
•
•
•
•
•
•
Demographics
Vaccination data: National Immunisation Register
Birth weight & gestation
Breast feeding
Reflux
Smoking in house
Day care attendance
Overcrowding
Atopic symptoms
Ear Disease history: symptoms, freq, treatment
General Medical history
Antibiotic History
......
Demographics N = 217
– Average Age
– Age range
– Gender
– Ethnicity
20 months
7 – 35.7 months
Male 68%: Female 32%
Maori 24% European 52%
Pacific 15% Other 9%
Questionnaire Data
– Day care attendance:
76%
– Family History of OME: 51%
– Antibiotic in last 4 weeks: 52%
Exposures and Viral detection
No variables correlated with the presence of virus in middle ear fluid or the nasopharynx
Indication for Surgery
Both AOM
& OME
28%
RAOM
42%
OME
30%
N = 217
Nasopharyngeal Samples:
Bacterial Culture N = 217
100
90
80
70
%
60
50
40
30
20
10
0
Any of 3
H inf
M cat
S pn
Nasopharyngeal Samples:
Bacterial Culture N = 217
100
60% positive for 2 or 3
otopathogens
90
80
70
%
60
50
40
30
20
10
0
Any of 3
H inf
M cat
S pn
Nasopharyngeal Samples:
Viral PCR n = 217
80
70
60
50
40
% 30
20
10
0
Nasopharyngeal Samples:
Bacterial Culture & Viral PCR n = 217
Negative
Viral only
%
Bacterial
& Viral
Bacterial
only
No significant correlation between any specific bacteria & virus
Middle ear findings
Grommet patients
n = 217
Number of ears
434
Middle ear samples
376
Patients with unilateral effusions
58 (27%)
Patients with unilateral effusions
159 (73%)
Serous
18%
Purulent
Dry
13%
12%
57%
Mucoid
Bacterial & Viral PCR
Middle Ear Fluid (n = 376)
Virus only
33%
19%
28%
20%
Middle Ear Samples: n = 376
Microbiology: Bacterial Culture
45
40
35
% 30
of 25
Samples
20
15
10
5
0
Any of 3
H.inf
M.cat
S.pn
Middle Ear Samples: n = 376
Microbiology: Bacterial Culture vs PCR
45
40
35
% 30
of
25
Samples
20
15
10
5
0
Any of 3 Any of 3
PCR
H.inf
H.inf
PCR
M.cat
M.cat
PCR
S.pn
S.pn
PCR
Middle Ear Samples:
Viral PCR n = 376
50
45
40
35
% 30
of 25
Samples 20
15
10
5
0
80
70
60
50
%40
30
20
10
0
Viral PCR: Nasopharynx vs MEF
Nasopharynx n = 217
MEF n = 217
Conclusions
Young children in NZ with ear disease:
•
•
•
•
Detection of bacteria & viruses in the nasopharynx is high
H.influenzae is the dominant bacteria in NP & MEF
Rhinovirus is the dominant virus in NP & MEF
Supportive evidence for mixed aetiology of otitis media
• Nasopharynx +ve:
• Viruses and bacteria in 68%
• Middle ear fluid +ve:
• Bacterial PCR 39%
• Viral PCR in 42%
• PCR for both Bacteria & Viruses in 19%
• Multivariate analyses did not identify significant correlations
between pathogens or exposures
OMIVI Research Team
Infectious Diseases Consultants
Research Nurses:
Emma Best (ADHB)
Tony Walls (CDHB)
David Murdoch (CDHB)
Debby Sandow (ADHB)
Eileen Andreas (ADHB)
Miriam Logan (ADHB)
Mandy Retter (CMDHB)
Kirstin Davey (CMDHB
Raewyn Wright (CDHB)
Louise Burgess(CDHB)
ENT Consultants:
Nikki Mills (ADHB)
Murali Mahadevan (ADHB)
Colin Barber (ADHB)
Michel Neeff (ADHB)
Colin Brown (ADHB)
Lesley Salkeld (ADHB & CMDHB)
Zahoor Ahmad (CMDHB)
Mel Souter (CDHB)
Research Assistant
Shamini Mahadevan
A+ Research Trust:
Genevieve Morris
Boris Mauwa (Accountant)
Microbiology: Scientific Officer
Statistician:
Trevor Anderson
Cameron Walker (UoAuck)
Thanks
Under 3 year old
New Zealander