Epidemiology of acute otitis media in children of Latin America and the Caribbean: A systematic review and meta-analysis

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Abstract

Background

Acute otitis media (AOM) is one of the most common childhood diseases requiring antimicrobial prescription in pre-school children. This systematic review aimed to estimate the AOM incidence, bacterial etiology and use of resources in children aged <6 years in Latin America and the Caribbean (LA&C).

Methods

A systematic search using keywords otitis or middle ear and inflammation was performed for articles published during 1988-2008 in MEDLINE, Cochrane Library, EMBASE, LILACS, generic and academic internet searches, Ministries of Health, PAHO, regional proceedings, reference lists and consulting experts. Pairs of reviewers independently selected articles and assessed their methodological quality with a checklist of essential items from the STROBE statement according to pre-specified criteria. Studies involving immune-competent children with AOM were considered. Arcsine transformations were used for proportion meta-analyses.

Results

Annual AOM incidence in four studies in children aged <5 years ranged from 1,171–36,000 episodes/100,000 children. Meta-analysis on etiology and pneumococcal serotypes included 18 studies and 125, 519 children with AOM from six LA&C countries. Meta-analysis per serotype showed that Streptococcus pneumoniae (32.4%; 95%CI = 27.1-38.0%) and Haemophilus influenzae (26%; 95%CI = 19.5-33.1%), including non-typeable H. influenzae (18.3%; 95%CI = 9.5-33.1%) were the most prevalent. The most commonly observed pneumococcal serotype was 19F (24.0%; 95% CI 17.0-32.0%). Data on use of health resources were scarce.

Conclusions

Streptococcus pneumoniae and H. influenzae were the most frequent AOM bacterial pathogens, consistent with the international literature from other regions. Future studies on AOM incidence and health resources usage will help better define the impact of this disease.

Highlights

► A systematic review of Latin American studies on AOM in children was performed. ► We were able to meta-analyse AOM bacterial etiology and pneumococcal serotypes. ► As in other regions S. pneumoniae and H. influenzae were the most frequent pathogens. ► The most commonly reported pneumococcal serotypes were 19F, 6B, 19A and 5. ► Scarce information on AOM health resources usage was identified.

Introduction

Acute otitis media (AOM) is one of the most common childhood infections and a frequent reason for pediatricians to prescribe antimicrobials [1]. It generally affects children <3 years of age and, if not properly treated, can cause significant hearing loss, which may potentially result in speech, language, and cognitive skills impairment [2]. The disease occurs in all ages, but it is more common in infancy. Fluid may persist for weeks or months after the onset of illness, despite appropriate antimicrobial treatment. In the United States (US) and Europe, AOM incidence has been estimated to range from 0.1 to 1.8 episodes/year per child <2 years of age, commonly with multiple consultations for an individual episode [3], [4], [5], [6]. In the first two years of life, more than 25% of children in almost all settings suffer from AOM caused by Streptococcus pneumoniae [6], [7], [8], while close to 80% of children have at least one AOM episode by the time they are three years old in the US [6], [8], [9].

A significant increase in the incidence of AOM has been observed due to socialization of children at younger ages (by attending day care centers or kindergartens), which increases the risk of infection [10]. In addition, other important risk factors are age, time of year, socioeconomic factors and large numbers of members within a household [10], [11], [12]. In developing countries, suppurative infections, including mastoiditis and meningitis, are still major complications of AOM [13]. According to estimates from the World Health Organization, annually 50,000 children aged <5 years die due to AOM-related complications in developing countries [14], [15]. This high mortality may be attributed to a late recognition of such complications (perforation and mastoiditis) or due to poor nutritional status [15]. In 2000, the annual estimates of healthcare expenditure to treat otitis media alone in the US were 5 billion dollars of which 40% were for children aged 1–3 years [16]. In addition, data from a US national survey in 1992 indicated that 30% of all antibiotic prescriptions were to treat otitis media in that age group [17].

In routine practice, obtaining etiological culture-confirmed diagnosis is uncommon, thus epidemiological information becomes crucial to determine empirical therapies based on evidence or for the implementation of vaccines that could prevent AOM. No comprehensive systematic reviews assessing the incidence, etiology and use of health resources for AOM in children <5 years of age in LA&C is available to date. Therefore, a detailed systematic review of the overall epidemiological data on AOM was performed to evaluate the burden of this disease.

Section snippets

Search strategy and eligibility criteria

We conducted a systematic search of articles published in the following electronic databases: CENTRAL, MEDLINE, EMBASE, and LILACS from January1988 to January 2008 (Supplementary data). The apparent stability of the bacterial etiology of AOM [18] over time (no secular trends) supported the utilization of an unrestrictive 20-year time window. We also performed a generic and academic Internet search and meta-search. An annotated search strategy for grey literature was included to retrieve

Results

Of the 195 published studies identified and reviewed, 18 studies met the inclusion criteria (Fig. 1). Four studies each (not necessarily the same studies) provided information on AOM incidence, pneumococcal serotypes, and health resource usage; and13 studies provided information on etiological agents. The study designs were classified as case-series (8), cohort (6), cross sectional (2) and before–after (2). Studies were conducted between 1979 and 1999, in the following six countries in LA

Discussion

Reliable epidemiological data on etiology and burden of AOM are important to make well-informed health policy decisions. This systematic review and meta-analysis provide data and identify information gaps about etiology, incidence and health economic impact of AOM in LA&C.

This systematic review in LA&C countries showed that the reported annual incidence of AOM was considerably lower than previously reported from developed countries [8], [45], [46]. In a study conducted in Boston, children had a

Acknowledgements

The authors would like to thank Farah Mecci, Eiman Jahangir, and Geetha Subramanyam for their writing assistance and Tatiana M Lanzieri for her editorial review. They also thank Patricia Aruj and Juan Calcagno (researchers) for helping with the screening and data abstraction, Daniel Comandé (librarian) for bibliographic support, Luz Gibbons (biostatistician) for helping with the statistical analyses, Eduardo Ortega-Barria for critical reviewing of the manuscript, Flávia R. M. Lamarão and

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