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Clinical guidelines

National guide to a preventive health assessment for Aboriginal and Torres Strait Islander people Second edition

Preventive interventions

Author Dr Sophie Couzos
Expert reviewers Associate Professor Amanda Leach, Associate Professor Peter Morris

Immunisation

Antenatal and childhood infections

Congenital and acquired hearing loss can be prevented by immunisation (rubella, measles, Hib, pneumococcus, meningococcus) by implementing the National Immunisation Schedule (and variations within state and territories) from birth/infancy. See Chapter 2 regarding recommendations to enhance immunisation coverage. In Australia, infection rates with measles and rubella remain extremely low and no cases of congenital rubella have been identified in the Aboriginal population for many years. The risk of congenital rubella remains, especially in immigrants.8 Rates of congenital syphilis in the Aboriginal population are extremely low but still occur. Fewer than 10 cases of congenital syphilis have been diagnosed annually since 2007.9 It is unclear what proportion have congenital hearing loss as a consequence. Screening antenates for syphilis is a key part of prevention of the disease (see Chapter 9: Antenatal care).

Pneumococcal

Pneumococcal conjugate vaccine (PCV) given to children will prevent a proportion from developing acute otitis media, but is not the primary reason for recommending it. The primary indication for PCV in the National Immunisation Program Schedule is for the prevention of invasive pneumococcal disease and pneumonia.

Systematic review of randomised controlled trials for the prevention of acute otitis media using 7-valent PCV (with CRM197-mutated diphtheria toxin carrier protein) shows marginal (7%) reduction but may mean ‘substantial reductions from a public health perspective’ in infant children.10 Protein D (Haemophilus influenzae derived) conjugated pneumococcal vaccine (11-valent) has 34% efficacy in reducing acute otitis media due to action against acute otitis media from both pneumococcus and non-typable H. influenzae.11 

Observational studies show reduced outpatient visits (20%) for acute and chronic otitis media from PCV.12 Other studies show reduced incidence of recurrent otitis media from PCV13,14 and reduced incidence of pressure equalising tube insertions from conjugate pneumococcal vaccination.13–15

In contrast, 23-valent polysaccharide pneumococcal vaccine (23vPPV) has not been shown to prevent otitis media.

13-valent PCV was approved by the US Food and Drugs Administration in 2010 for the prevention of invasive pneumococcal disease as well as otitis media caused by the seven serotypes also covered by 7-valent PCV, however, ‘no efficacy data for prevention of otitis media are available for the six additional serotypes’.16

10-valent PCV (protein D conjugate: Synflorix®) was Therapeutic Goods Administration approved in Australia in July 2009 as an alternative to 7-valent PCV for the prevention of childhood pneumococcal infections (including invasive disease, pneumonia and acute otitis media). 13-valent PCV was approved by the Advisory Committee on Prescription Medicines in 2010,17 for ‘Active immunisation for the prevention of disease caused by Streptococcus pneumoniae serotypes 1, 3, 4, 5, 6A, 6B, 7F, 9V, 14, 18C, 19A, 19F and 23F (including invasive disease, pneumonia and acute otitis media) in infants and children from 6 weeks up to 5 years of age’. The vaccine is not Therapeutic Goods Administration approved for the prevention of otitis media due to non-typable H. influenzae.

This indication was approved by the Therapeutic Goods Administration in May 2010, and announced by the Federal Minister for Health in February 2011. It took effect from 1 April 2011 on the Pharmaceutical Benefits Scheme (PBS).

Influenza

Influenza vaccination in children will prevent a proportion from developing acute otitis media, but is not the primary reason for recommending it. The efficacy of inactivated influenza vaccine in the prevention of acute otitis media is inconclusive.

The National Immunisation Program Schedule recommends influenza vaccine for the prevention of influenza and pneumonia. All the influenza vaccines currently available in Australia are either split virion or subunit vaccines prepared from purified inactivated influenza virus which has been cultivated in embryonated hens’ eggs.18

The use of influenza vaccine for the prevention of otitis media is not subsidised under the Australian National Immunisation Program Schedule.

A 2005 systematic review showed influenza vaccination was no different from placebo.19 A 2007 meta-analysis showed a 51% reduction in acute otitis media overall (with 32% reduction in acute otitis media using inactivated influenza vaccine in children).20 

Recently, influenza vaccination (inactivated trivalent virosomal adjuvanted) was effective in relative reduction of acute otitis media episodes (6 month follow up) by 34% compared with unvaccinated controls (in children prone to recurrent otitis media).21

Episodes of acute otitis media were reduced by 71% in a randomised controlled trial involving children aged 18–72 months receiving inactivated trivalent influenza vaccine. However, ‘outside of the influenza seasons, no significant effects of vaccinations were demonstrated on the studied outcomes’.22

Pooled data from randomised controlled trials of children receiving live attenuated influenza vaccine (aged 6–83 months) showed a 38% relative reduction in the development of acute otitis media.23

Screening

Newborn

Because 50% of children with hearing loss have no identifiable risk factors, universal screening (instead of targeted screening of high risk groups) has been proposed to detect children with permanent congenital hearing loss early in life. Neonatal hearing screening is believed to have resulted in significant cost savings to the health system.24 

Australia operates neonatal screening programs in all states/territories to varying degree as some offer universal hearing screening and others offer targeted screening (many other countries also have a universal newborn hearing screening program).

In 2009, the Council of Australian Governments agreed to ensure that by the end of 2010 every child born in Australia has access to screening for congenital hearing impairments.25 This program is being coordinated at the federal level with states and territories, although there is no specific federal funding for this now national approach to newborn hearing screening. Guidelines and standards have been endorsed by the Australian Health Ministers’ Advisory Council and performance indicators for the monitoring of the program are in development. A formal evaluation of cost:benefit has not been proposed (pers. comm. Department of Health and Ageing, July 2011).

Permanent congenital hearing loss (PCHL) occurs in 1–2 infants per 1000 births. Prevalence of PCHL is significantly higher than prevalence of other conditions for which newborn screening currently occurs (eg. phenylketonuria 1 per 10 000; hypothyroidism 3 per 10 000; cystic fibrosis 4 per 10 000). Newborn hearing screening leads to earlier identification and intervention, and ultimately leads to better language development. In the absence of newborn hearing screening, three out of 4 children with PCHL remain undiagnosed by 12 months of age and their capacity for normal language and cognitive development is greatly diminished.

In Western Australia, Newborn Hearing Screening (NBHS) services have operated in selected metropolitan hospitals since 2000. From 2010, all West Australian birthing hospitals will be required to screen all newborns for permanent congenital hearing loss.26 In 2011, it was reported that more than 95% of all newborns in Western Australia had received neonatal hearing screening.27 Few data are available from other jurisdictions.

Several systematic reviews have examined universal newborn hearing screening. The United States Preventive Services Task Force recommends screening for hearing loss in all newborn infants before 1 month of age. Infants who do not pass the newborn screening should undergo audiologic and medical evaluation before 3 months of age. This is based on good quality evidence that early detection improves language outcomes, although the net benefit (taking account of risk of harms) is moderate. The number needed to screen to diagnose one case is 878 and 178 for universal newborn hearing screening and targeted screening programs, respectively.28

A Cochrane review of randomised controlled trials concluded that the long term effectiveness of universal newborn hearing screening programs has not been established. The review could not identify any randomised trials comparing the long term results (psychological, language and educational related outcomes) of either universal, targeted or opportunistic newborn hearing screening programs.29

Another systematic review concurred that patient relevant parameters, such as social aspects, quality of life, and educational development, have not been adequately investigated, thereby limiting understanding of the impact of newborn hearing screening.30

Early childhood

Specific recommendations for the Aboriginal and Torres Strait Islander population for hearing screening from early childhood are based on the high incidence and prevalence of otitis media in the Aboriginal population. Screening for otitis media with effusion in non-Indigenous children is not recommended by general guidelines (eg. the RACGP red book).

The Senate Community Affairs Reference Committee24 has recommended that ‘the Council of Australian Governments extends its commitment for universal newborn hearing screening to include a hearing screening of all children on commencement of their first year of compulsory schooling. Given the crisis in ear health among Aboriginal and Torres Strait Islander people, the committee believes urgent priority should be given to hearing screenings and follow up for all Indigenous children from remote communities on commencement of school’.

However, according to the Darwin Otitis Guideline Group, in regions with near- universal conductive hearing loss due to infection (intermittent/recurrent), it is unlikely that hearing screening at school entry will reveal information that isn’t already known. In regions with sporadic hearing loss, monitoring for hearing loss is the preferred recommendation. School entry screening might pick up undetected deafness (usually otitis media with effusion) warranting personal intervention, but it is unclear if this outcome justifies school entry screening. The Darwin Otitis Guideline Group did not recommend school entry screening for hearing loss detection in populations with high levels (‘near universal’) of otitis media and consequent conductive hearing loss. The group recommended that ‘regular surveillance (with appropriate testing when indicated) is preferred to school entry screening’.

In a cross-sectional analysis over time, 19% of Aboriginal children screened at school age screening program had unilateral/bilateral mild–moderate hearing loss.31 There was no cohort or comparison group of non-Indigenous children, so it is not possible to assess this significance of this level. This is the only recent school screening report in Australia.

The US Preventive Services Task Force provides no recommendations for hearing screening beyond those for the neonatal period. The American Academy of Pediatrics recommends hearing screening at 4 years, and definitive hearing testing at intervals in those children with risk factors (eg. recurrent otitis media). No specific reference is made to school screening.

Behavioural

Parental vigilance for the detection of hearing loss in children is crucial. Around one-quarter of hearing loss affected children had their loss identified and initiated by parental suspicion.32,33 Other sources of identification include well- baby checks (20%) and through risk factors (31%).32 

Studies report parents are poor predictors of hearing loss from otitis media with effusion.34,35 

Breastfeeding

A meta-analysis of observational studies found that prolonged breastfeeding for at least 3 months reduces the risk of acute otitis media by 13%.36 A cohort study found 6 month exclusive breastfeeding protective against infectious disease.37

Smoking

Exposure to passive smoke is confirmed risk factor in cohort studies38 and meta-analysis of those studies.39 Evidence that smoking cessation favourably influences the progression of otitis media with effusion is lacking.

Swimming

The Norwegian Mother and Child Cohort Study conducted by the Norwegian Institute of Public Health in children born between 1999 and 2005 followed from birth to the age of 18 months. Children who were baby swimming (at 6 months) were not more likely to have lower respiratory tract infections, to wheeze or to have otitis media.40

Two meta-analyses of randomised controlled trials and cohort studies have investigated the impact of swimming on acute otitis media occurrence (or otorrhoea) after tympastomy tube insertion. They both found that swimming made no difference to the occurrence of acute otitis media (or otorrhoea).41,42 

Children with chronic suppurative otitis media who swim may also benefit, as the introduction of swimming pools in two remote Aboriginal communities led to a reduction in the prevalence of tympanic membrane perforations over 18 months,43 although this was not a controlled trial.

Antibiotics

A Cochrane review of 13 randomised controlled trials found long term (>6 weeks) prophylactic antibiotics can prevent episodes of acute otitis media, but children in the trials mostly had recurrent otitis media.44 A meta-analysis showed that while oral antibiotics used in acute otitis media had a marginal effect in preventing asymptomatic middle ear effusion, this benefit was outweighed by other factors such as antibiotic resistance and treatment to prevent effusion could not be warranted.45 

There is little evidence that acute otitis media can be prevented by commencing treatment with antibiotics at the onset of upper respiratory tract symptoms or as prophylaxis generally (as distinct from prophylaxis in children with known recurrent otitis media, which is effective).46

Management of detected otitis media should proceed according to clinical practice guidelines, which are distinct for the Aboriginal population.1

Prophylactic antiviral drugs

It has been reported that acute otitis media occurs in 20–50% of children under 6 years of age after influenza.47 Acute otitis media was significantly less likely in patients with confirmed influenza infection treated with neuraminidase inhibitors versus placebo.48

Another systematic review examined the effect of antiviral drugs on the secondary effects of influenza (such as acute otitis media) as well as preventing influenza in family contacts of the index case: ‘Effects of neuraminidase inhibitors on rates of otitis media were no different in children aged 5–6 and 12 but were significantly lower in children younger than 5 years. With a household prophylaxis strategy, 13 children would need to be treated with a 10 day course of zanamivir or oseltamivir to prevent one additional child developing influenza … Reductions of secondary complications could be an important factor in the decision to treat and should be balanced with the higher rates of adverse effects, particularly vomiting, with oseltamivir’.47 

It appears therefore that in children affected with influenza, there is the option of antiviral therapy to prevent acute otitis media (while considering the number needed to treat to prevent one case of acute otitis media) or antibiotics when/if acute otitis media develops. In conclusion, there is little rationale in opting for neuraminidase inhibitors to prevent the need for antibiotic treatment for acute otitis media as a complication of influenza.

Housing

Early and persistent otitis media could be prevented if overcrowded living conditions of Aboriginal communities were improved.39 A strong independent association was demonstrated between ‘reports of respiratory infection’ and the overall ‘functional condition’ of those houses examined over 2003–04. Statistically significant associations were found between carers’ report of the presence of ear infections in children with the level of toilet infrastructure and poor infrastructure overall. The study confirms ‘the potential for general improvements in the functional state of housing infrastructure to improve the health of children in these communities, most notably through reducing respiratory infections’.49

Overcrowded housing has also been shown to increase the risk of nasopharyngeal carriage of Streptococcus pneumoniae, Moraxella catarrhalis and non-typeable H. influenzae in Aboriginal and non-Aboriginal children. Nasopharyngeal carriage of these pathogens is a well established predictor of early onset acute otitis media and chronic otitis complications. Overcrowded housing facilitates household transmission of otitis pathogens.50

More than a quarter of the Aboriginal population live in a house deemed to need extra bedrooms, compared to just 5.7% of non-Indigenous people. In some remote areas in the Northern Territory, the highest rates of overcrowding were reported with over 70% of people living in overcrowded conditions (needing more bedrooms).51

Handwashing

Few studies have evaluated the effects of handwashing, nose-blowing and facial cleanliness on the prevention of acute otitis media.

A randomised controlled study examining handwashing in child day care centres found that children in the intervention group had fewer visits to a doctor because of an attack of acute otitis media with effusion and received 24% fewer prescriptions for anti-microbials. There was general compliance with the handwashing instructions.52

Regarding the prevention of the pathogens that transmit acute otitis media, poor handwashing was a predictor of non-typable H. influenzae throat carriage in children from child care centres.53 The risk of pneumococcal hand contamination was eight times higher in Aboriginal children aged 3–7 years from a remote community than in children younger than 4 years of age from urban childcare centres (37% vs 4%), further supporting the important role of handwashing in the prevention of otitis media.54

Noise induced hearing loss

It is likely that in many Aboriginal families, noise exposure exceeds the allowable daily exposure of 85 decibels (dB) averaged over an 8 hour working day (occupational standards), according to a recent survey conducted mostly in the Northern Territory. Overcrowding is likely to contribute to excessive noise exposure. A significant risk of noise induced hearing loss is believed to occur in the majority of persons exposed to levels which exceed this on a long term basis. Such exposure may create ‘a “second wave” of preventable noise-induced sensori-neural hearing loss for those in Indigenous communities’. Few health professionals and families are aware of the fact that excessive exposure to loud noise over prolonged periods can damage hearing. In terms of interventions, Aboriginal and Torres Strait Islander health workers have an important role to play since they can best inform families about the dangers of too much loud noise, particularly for children with a history of ear disease.55

Few studies have explored the prevalence of noise related hearing disorders affecting Aboriginal people. The hearing status of 109 Aboriginal prisoners in Victoria revealed that 36% had high frequency hearing loss and that this was most consistent with a noise induced loss. Ninety-two percent had reported exposures to loud noise.4

Recommendations: Hearing loss
Preventive intervention typeWho is at risk?What should be done?How often?Level/strength of evidence
Immunisation Children aged <15 years Vaccination is recommended to prevent infections that may lead to congenital or acquired hearing loss (rubella, measles, H. influenzae type b, meningococcus). (See Chapter 2: Child health) As per National Immunisation Program Schedule (NIPS) and state/territory schedules IA18
Pneumococcal conjugate vaccination (13-valent PCV) is recommended during infancy to prevent invasive disease, pneumonia and acute otitis media*17 Age 2, 4 and 6 months, as per NIPS and state/territory schedules I–IIA10,11
Annual influenza vaccination (inactivated virus) is recommended for any person ≥6 months of age who wishes to reduce the likelihood of becoming ill with influenza. Vaccination may reduce the incidence of acute otitis media as a secondary complication of influenza As per NIPS and state/territory schedules IC19,20,23
All pregnant women Offer testing for rubella immunity and syphilis serology to prevent infections which may lead to congenital hearing loss See Chapter 9: Antenatal care N/A
Screening Newborn infants Ensure parents of newborn infants are aware of the universal neonatal hearing screening program being implemented in each state/territory and have had their newborn screened for congenital hearing impairment Prior to age 1 month IC28–30
Children aged <15 years Encourage parents to be aware of child developmental milestones in the early detection of hearing loss (see Table 7.1). Parental suspicion of hearing loss should always be investigated (see Table 7.2). Where relevant, provide advice regarding free hearing assessment (see below) Opportunistic, antenatal and postnatal checks, and as part of an annual health assessment GPP2
Conduct ear examinations (otoscopy) in order to detect unrecognised acute or chronic otitis media. If detected, refer to clinical practice guidelines for management (see Resources) Opportunistic and as part of an annual health assessment GPP2
Children aged <5 years and older children at high risk of hearing impairment† Monitor for hearing loss Opportunistic and as part of an annual health assessment GPP2
Use the following audiological tools to monitor for hearing loss: simplified parental questionnaires (see Table 7.1), and pneumatic otoscopy or tympanometry (in children older than 4 months of age). These methods do not assess hearing
Pneumatic otoscopy or tympanometry is used to identify otitis media with effusion (with possible conductive hearing loss). Refer to clinical practice guidelines for the identification and management of otitis media with effusion (see reference 1 and 2 and Resources). Those with suspected hearing loss (or caregiver concerns) should be referred as shown in Table 7.2
Opportunistic and as part of an annual health assessment GPP2
School entry aged children The routine hearing screening of all children upon commencement of their first year of compulsory schooling may have limited public health value and is not encouraged N/A GPP2
Adults aged >15 years Monitor for hearing impairment by questioning, provide advice regarding free hearing assessment, and make referrals when appropriate As part of an annual health assessment GPP6
All people Inform patients that free hearing assessment (and rehabilitation/hearing aids if hearing loss is confirmed) can be obtained as part of the Australian Government Hearing Services Program and the Community Services Obligation (check eligibility criteria‡) Opportunistic GPP57–60
Behavioural Pregnant women and postnatal period Promote exclusive breastfeeding for at least 4 months (and preferably to 6 months) to reduce the risk of infants acquiring acute otitis media. Refer women to breastfeeding support programs if needed Opportunistic, antenatal and postnatal checks, and as part of an annual health assessment IB36
All smokers Promote smoking cessation and the need to avoid children being exposed to cigarette smoke, as passive exposure increases the risk of acute, recurrent and chronic otitis media. (See Chapter 1: Lifestyle, section on smoking cessation) Opportunistic and as part of an annual health assessment IA39
All people Swimming (sea, clean fresh water) should be permitted including in children with a prior history of otitis media (all forms) Opportunistic IA40–43
All people A video otoscope may assist in helping patients and families to understand ear disease. This may lead to greater engagement in its prevention and management Opportunistic GPP2
Chemo-prophylaxis Children aged <15 years The use of prophylactic antibiotics in order to prevent the onset of acute otitis media is not recommended, except in children with recurrent otitis media§ Opportunistic IA42,43
The use of prophylactic antiviral drugs in those with confirmed influenza for the purpose of preventing the onset of acute otitis media is not recommended Opportunistic IA39,48
Environmental Children aged <15 years Assess children at high risk of hearing impairment† with regard to their housing situation (ie. if overcrowding is likely, functional condition of housing) and refer to social support services for housing assistance if indicated (see Table 7.3)61 Annually IIIC39,49,50
Encourage nose-blowing, facial cleanliness and handwashing of children, in order to prevent the transmission of infectious disease. Frequent hand washing in child care centres can prevent the occurrence of childhood infections and episodes of acute otitis media Opportunistic IIC52,53
All people Inform families of the danger of loud noise (and for prolonged periods), especially for children with a history of ear disease (see Resources) Opportunistic GPP55
* Aboriginal and Torres Strait Islander children in high risk areas are recommended to also receive 23-valent polysaccharide vaccine (PSV) as a booster dose between 18 and 24 months of age as indicated for the prevention of invasive pneumococcal disease. High risk areas include the Northern Territory, Queensland, South Australia and Western Australia. This vaccine is not recommended for children in New South Wales, the Australian Capital Territory, Victoria or Tasmania18
† High risk of hearing impairment: those from socioeconomically deprived communities and from regions with a high prevalence of otitis media
‡ Australian Government Hearing Services Program eligibility (Voucher system) includes all Australian pensioner/sickness allowance recipients 21 years and older including a dependent of a person in that category.58 For those under 21 years, certain remote area patients, adults with complex hearing needs, Aboriginal and Torres Strait Islander persons >50 years of age or Aboriginal participants in CDEP programs of any age, the Community Services Obligation component also provides free hearing services59 and can be accessed by the federally funded and sole provider of these services: ‘Australian Hearing’.57 The CSO can also be accessed by those aged 21–26 years.60 Private hearing clinics (eg. Hearing Life) provide free hearing assessments to anyone 21 years and over
§ Recurrent otitis media: the occurrence of three or more episodes of acute otitis media in a 6 month period, or occurrence of four or more episodes in the past 12 months2
Table 7.1. Hearing related growth milestones in children
Simplified parental questionnaires can elicit a child’s progress through the following hearing related growth milestones:
  • 3–6 months: not communicating by vocalising or eye gaze
  • 9 months: poor feeding or oral coordination
  • 12 months: not babbling
  • 20 months: only pointing or using gestures (ie. not speaking)
  • 24 months: using <20 words, not following simple requests
  • 30 months: no two-word combinations
Source: Darwin Otitis Guideline Group 20102
Table 7. 2. Criteria for referral of children with suspected hearing loss, hearing related problems elicited through simplified parental questionnaires (Table 7. 1), and/or caregiver concerns
Age of childRefer to
<3 years Major regional hearing centre to determine the level of loss
<5 years and older children at high risk of hearing impairment* Paediatrician and audiologist for appropriate developmental assessment and hearing tests
<15 years Audiologist or ENT specialist for full hearing assessment
* High risk of hearing impairment refers to people from socioeconomically deprived communities and from regions with a high prevalence of otitis media
Source: Darwin Otitis Guideline Group 20102
Table 7.3. Definition of overcrowded housing circumstances
Households that do not meet the following requirements are deemed to be overcrowded:
  • There should be no more than two persons per bedroom
  • Children younger than 5 years of age of different sexes may reasonably share a bedroom
  • Children 5 years of age or older of opposite sex should have separate bedrooms
  • Children younger than 18 years of age and the same sex may reasonably share a bedroom
  • Single household members 18 years or over should have a separate bedroom, as should parents or couples
Source: Biddle N 200851

Resources

Recommendations for clinical care guidelines on the management of otitis media in Aboriginal and Torres Strait Islander populations (Darwin Otitis Guideline Group in collaboration with the Office for Aboriginal and Torres Strait Islander Health Otitis Media Technical Advisory Group)
www.health.gov.au/ internet/main/publishing.nsf/ Content/64B3D2636590623FCA 25722B0083428D/$File/om_pdf_version.pdf

Therapeutic Guidelines: Antibiotics
www.tg.org.au/?sectionid=41

Noise destroys your hearing (Australian Hearing)
www.hearing.com.au/ upload/media-room/ Noise-destroys-your-hearing.pdf.

References

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