Author Dr Sophie Couzos
Expert reviewers Associate Professor Amanda Leach, Associate Professor Peter Morris
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 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 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
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
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.
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
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
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.
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.
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.
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
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 type||Who is at risk?||What should be done?||How often?||Level/strength of evidence|
||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
|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
|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
|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
||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
|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
|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
|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
|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
|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
|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
||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‡)
||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
||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
||Swimming (sea, clean fresh water) should be permitted including in children with a prior history of otitis media (all forms)
||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
||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§
|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
||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
|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
||Inform families of the danger of loud noise (and for prolonged periods), especially for children with a history of ear disease (see Resources)
|* 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 child||Refer to|
||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
||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
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
Noise destroys your hearing (Australian Hearing)
www.hearing.com.au/ upload/media-room/ Noise-destroys-your-hearing.pdf.
- Antibiotic Expert Group. Therapeutic guidelines: antibiotic. Version 14. Melbourne: Therapeutic Guidelines Limited, 2010. Cited October 2011. Available at www.tg.org.au/?sectionid=41.
- Quinn S, Rance G. The extent of hearing impairment among Australian Indigenous prisoners in Victoria, and implications for the correctional system. Int J Audiol 2009;48(3):123–34.
- Ridley G, Zurynski Y, Elliot E, editors. Australian Paediatric Surveillance Unit biannual research report 2007–2008. Sydney: Australian Paediatric Surveillance Unit, 2008.
- Ward JS, Guy RJ, Akre SP, et al. Epidemiology of syphilis in Australia: moving toward elimination of infectious syphilis from remote Aboriginal and Torres Strait Islander communities? Med J Aust 2011;194(10):525–29.
- Jansen AG, Hak E, Veenhoven RH, Damoiseaux RA, Schilder AG, Sanders EA. Pneumococcal conjugate vaccines for preventing otitis media. Cochrane Database Syst Rev 2009;Apr 15;(2):CD001480.
- Prymula R, Peeters P, Chrobok V, et al. Pneumococcal capsular polysaccharides conjugated to protein D for prevention of acute otitis media caused by both Streptococcus pneumoniae and non-typable Haemophilus influenzae: a randomised double-blind efficacy study. Lancet 2006;367(9512):740–8.
- Grijalva CG, Poehling KA, Nuorti JP, Zhu Y, Martin SW, Edwards KM, et al. National impact of universal childhood immunization with pneumococcal conjugate vaccine on outpatient medical care visits in the United States. Pediatrics 2006;118(3):865–73.
- Fireman B, Black SB, Shinefield HR, Lee J, Lewis E, Ray P. Impact of the pneumococcal conjugate vaccine on otitis media. Pediatr Infect Dis J 2003;22(1):10–6.
- Poehling KA, Szilagyi PG, Grijalva CG, et al. Reduction of frequent otitis media and pressure-equalizing tube insertions in children after introduction of pneumococcal conjugate vaccine. Pediatrics 2007;119(4):707–15.
- Palmu AA, Verho J, Jokinen J, Karma P, Kilpi TM. The seven-valent pneumococcal conjugate vaccine reduces tympanostomy tube placement in children. Pediatr Infect Dis J 2004;23(8):732–8.
- Nuorti JP, Whitney CG. Prevention of pneumococcal disease among infants and children — use of 13-valent pneumococcal conjugate vaccine and 23-valent pneumococcal polysaccharide vaccine. Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Morb Mortal Wkly Rep serial on the Internet 2010. Cited October 2011; 59(RR-11). Available at www.cdc.gov/ mmwr/pdf/rr/rr5911.pdf.
- Advisory Committee on Prescription Medicines. ACPM 268th meeting recommendations. Canberra: Australian Government Therapeutic Goods Administration, 2010. Updated June 2010. Cited August 2011. Available at www.tga.gov.au/ about/acpm-recommendations-2010–0268.htm.
- National Health and Medical Research Council. The Australian Immunisation Handbook, 9th edn. Canberra: Commonwealth of Australia, 2008. Cited October 2011. Available at www.health.gov.au/ internet/immunise/publishing.nsf/ content/handbook-home.
- Jefferson T, Smith S, Demicheli V, Harnden A, Rivetti A, Di Pietrantonj C. Assessment of the efficacy and effectiveness of influenza vaccines in healthy children: systematic review. Lancet 2005;365(9461):773–80.
- Manzoli L, Schioppa F, Boccia A, Villari P. The efficacy of influenza vaccine for healthy children: a meta-analysis evaluating potential sources of variation in efficacy estimates including study quality. Pediatr Infect Dis J 2007;26(2):97–106.
- Marchisio P, Esposito S, Bianchini S, et al. Efficacy of injectable trivalent virosomal-adjuvanted inactivated influenza vaccine in preventing acute otitis media in children with recurrent complicated or noncomplicated acute otitis media. Pediatr Infect Dis J 2009;28(10):855–9.
- Jansen AG, Sanders EA, Hoes AW, van Loon AM, Hak E. Effects of influenza plus pneumococcal conjugate vaccination versus influenza vaccination alone in preventing respiratory tract infections in children: a randomized, double-blind, placebo-controlled trial. J Pediatr 2008;153(6):764–70.
- Block SL, Heikkinen T, Toback SL, Zheng W, Ambrose CS. The efficacy of live attenuated influenza vaccine against influenza-associated acute otitis media in children. Pediatr Infect Dis J 2011;30(3):203–7.
- The Senate Community Affairs References Committee. Hear us: inquiry into hearing health in Australia. Canberra: Senate Community Affairs Committee Secretariat, 2010. Cited October 2011. Available at www.aph.gov.au/ senate/committee/clac_ctte/hearing_ health/report/report.pdf.
- Council of Australian Governments. COAG Communiqué 2 July 2009. Darwin: Council of Australian Governments’ Meeting, 2009. Cited October 2011. Available at www.coag.gov.au/ coag_meeting_outcomes/2009–07–02/docs/20090702_communique.pdf.
- Government of Western Australia. Operational directive: newborn hearing screening. Perth: Department of Health, Government of Western Australia, 2009.
- Hames K. Newborn hearing program exceeds target. Perth: The Liberal Party of Australia Western Australian Division, 2011. Updated April 2011. Cited October 2011. Available at www.wa.liberal.org.au/ item/5258.
- US Preventive Services Task Force. Universal screening for hearing loss in newborns: US Preventive Services Task Force recommendation statement. Pediatrics 2008;122(1):143–8.
- Puig T, Municio A, Meda C. Universal neonatal hearing screening versus selective screening as part of the management of childhood deafness. Cochrane Database Syst Rev 2005;Apr 18;(2):CD003731.
- Wolff R, Hommerich J, Riemsma R, Antes G, Lange S, Kleijnen J. Hearing screening in newborns: systematic review of accuracy, effectiveness, and effects of interventions after screening. Arch Dis Child 2010;95(2):130–5.
- Williams CJ, Coates HL, Pascoe EM, Axford Y, Nannup I. Middle ear disease in Aboriginal children in Perth: analysis of hearing screening data,1998–2004. Med J Aust 2009;190(10):598–600.
- Marttila TI, Karikoski JO. Initiators in processes leading to hearing loss identification in Finnish children. Eur Arch Otorhinolaryngol 2005;262(12):975–8.
- Watkin PM, Baldwin M, Laoide S. Parental suspicion and identification of hearing impairment. Arch Dis Child 1990;65(8):846–50.
- Lo PS, Tong MC, Wong EM, van Hasselt CA. Parental suspicion of hearing loss in children with otitis media with effusion. Eur J Pediatr 2006;165(12):851–7.
- Stewart MG, Ohlms LA, Friedman EM, Sulek M, Duncan NO,3rd, Fernandez AD, et al. Is parental perception an accurate predictor of childhood hearing loss? A prospective study. Otolaryngol Head Neck Surg 1999;120(3):340–4.
- Uhari M, Mantysaari K, Niemela M. A meta-analytic review of the risk factors for acute otitis media. Clin Infect Dis 1996;22(6):1079–83.
- Ladomenou F, Moschandreas J, Kafatos A, Tselentis Y, Galanakis E. Protective effect of exclusive breastfeeding against infections during infancy: a prospective study. Arch Dis Child 2010;95(12):1004–8.
- Jacoby PA, Coates HL, Arumugaswamy A, Elsbury D, Stokes A, Monck R, et al. The effect of passive smoking on the risk of otitis media in Aboriginal and non-Aboriginal children in the Kalgoorlie-Boulder region of Western Australia. Med J Aust 2008;188(10):599–603.
- Couzos S, Metcalf S, Murray R. Systematic review of existing evidence and primary care guidelines on the management of otitis media (middle ear infection) in Aboriginal and Torres Strait Islander populations. Canberra: Office for Aboriginal and Torres Strait Islander Health, Commonwealth Department of Health and Aged Care, 2001. Cited October 2011. Available at www.health.gov.au/ internet/main/publishing.nsf/Content/ health-oatsih-pubs-Syst+review.
- Nystad W, Haberg SE, London SJ, Nafstad P, Magnus P. Baby swimming and respiratory health. Acta Paediatr 2008;97(5):657–62.
- Carbonell R, Ruíz-García V. Ventilation tubes after surgery for otitis media with effusion or acute otitis media and swimming. Systematic review and meta-analysis. Int J Pediatr Otorhinolaryngol 2002;66(3):281–9.
- Lee D, Youk A, Goldstein NA. A meta-analysis of swimming and water precautions. Laryngoscope 1999;109(4):536–40.
- Lehmann D, Tennant MT, Silva DT, et al. Benefits of swimming pools in two remote Aboriginal communities in Western Australia: intervention study. BMJ 2003;327(7412):415–9.
- Leach AJ, Morris PS. Antibiotics for the prevention of acute and chronic suppurative otitis media in children. Cochrane Database Syst Rev 2006;Oct 18;(4):CD004401.
- Koopman L, Hoes AW, Glasziou PP, et al. Antibiotic therapy to prevent the development of asymptomatic middle ear effusion in children with acute otitis media: a meta-analysis of individual patient data. Arch Otolaryngol Head Neck Surg 2008;134(2):128–32.
- Heikkinen T, Ruuskanen O, Ziegler T, Waris M, Puhakka H. Short-term use of amoxicillin-clavulanate during upper respiratory tract infection for prevention of acute otitis media. J Pediatr 1995;126(2):313–6.
- Shun-Shin M, Thompson M, Heneghan C, Perera R, Harnden A, Mant D. Neuraminidase inhibitors for treatment and prophylaxis of influenza in children: systematic review and meta-analysis of randomised controlled trials. BMJ 2009;339:b3172.
- Falagas ME, Koletsi PK, Vouloumanou EK, Rafailidis PI, Kapaskelis AM, Rello J. Effectiveness and safety of neuraminidase inhibitors in reducing influenza complications: a meta-analysis of randomized controlled trials. J Antimicrob Chemother 2010;65(7):1330–46.
- Bailie R, Stevens M, McDonald E, Brewster D, Guthridge S. Exploring cross-sectional associations between common childhood illness, housing and social conditions in remote Australian Aboriginal communities. BMC Public Health 2010:10:147.
- Jacoby P, Carville KS, Hall G, et al. Crowding and other strong predictors of upper respiratory tract carriage of otitis media-related bacteria in Australian Aboriginal and non-Aboriginal children. Pediatr Infect Dis J 2011;30(6):480–5.
- Biddle N. The scale and composition of Indigenous housing need, 2001–06. CAEPR working paper no. 47/2008. Canberra: Centre for Aboriginal Economic Policy Research, Australian National University, 2008. Cited October 2011. Available at http://caepr.anu.edu.au/ sites/default/files/Publications/WP/ CAEPRWP47.pdf.
- Uhari M, Mottonen M. An open randomized controlled trial of infection prevention in child day-care centers. Pediatr Infect Dis J 1999;18(8):672–7.
- Barbosa-Cesnik C, Farjo RS, Patel M, et al. Predictors for Haemophilus influenzae colonization, antibiotic resistance and for sharing an identical isolate among children attending 16 licensed day-care centers in Michigan. Pediatr Infect Dis J 2006;25(3):219–23.
- Stubbs E, Hare K, Wilson C, Morris P, Leach AJ. Streptococcus pneumoniae and noncapsular Haemophilus influenzae nasal carriage and hand contamination in children: a comparison of two populations at risk of otitis media. Pediatr Infect Dis J 2005;24(5):423–8.
- Howard D, McLaren S, Fasoli L, Wunungmurra A. Dangerous listening: the exposure of Indigenous people to excessive noise. Aborig Isl Health Work J 2011;35:3–8.
- Australian Hearing. Noise destroys your hearing: how much noise can cause permanent damage? Sydney: Australian Hearing. Cited November 2011. Available at www.hearing.com.au/ upload/media-room/Noise-destroys-your-hearing.pdf.
- Australian Hearing. Australian Hearing Annual Report 2010. Canberra: The Australian Government Department of Human Services, 2010. Cited October 2011. Available at www.hearing.com.au/annual-reports.
- Department of Health and Ageing. The Australian Government Hearing Services Program. Canberra: Commonwealth of Australia, 2003. Updated August 2010. Cited October 2011. Available at www.health.gov.au/ internet/main/publishing.nsf/Content/health-hear-contacts-clsline.htm.
- Department of Health and Ageing. The Australian Government Hearing Services Program. Canberra: Commonwealth of Australia, 2011. Updated August 2011. Cited October 2011. Available at www.health.gov.au/hear.
- Department of Health and Ageing. New budget measures for the Hearing Services Program. Canberra: Commonwealth of Australia, 2011. Updated May 2011. Cited October 2011. Available at www.health.gov.au/internet/ main/publishing.nsf/Content/health-hear-clientbudget.
- Australian Bureau of Statistics. Australian Social Trends 2003, cat. no. 4102.0. Canberra: ABS, 2003.